Neonatal cord blood eucapnic pH: A potential biomarker predicting the need for transfer to the NICU.

INTRODUCTION: The best biomarker for neonatal metabolic acidosis (NMA) and its related complications is still a matter of debate. Umbilical artery (Ua) cord pH is not sufficiently specific, as is lactatemia, while base deficit is considered to offer no added value. From a physiological point of view, the calculated neonatal eucapnic pH is a more specific marker for neonatal metabolic acidosis and may be a better predictor of birth complications of hypoxic origin, because complications related to asphyxia are always preceded by neonatal depression leading to a transfer to a neonatal intensive care unit (NICU) for close monitoring. OBJECTIVE: This study aimed to test the hypothesis that in a group of neonates with significant acidemia, neonatal eucapnic pH (pH euc-n) predicts NICU admission better than the Ua cord pH does. METHODS: From a cohort of 5,392 infants all born at ≥35 weeks' gestation, we identified a group of 30 cases with Ua cord pH <7.0. We calculated the area under the curve (AUC) for pH euc-n and Ua cord pH using the receiver-operating characteristic (ROC) curve and compared the performance of these biological markers in predicting transfer to the NICU. Cut-off points were determined by selecting the best value of the positive likelihood ratio that maximizes the accuracy of prediction. RESULTS: From the 30 newborns diagnosed with significant acidemia, four infants were transferred to the NICU. No case of neonatal encephalopathy was observed. In these infants, the pH euc-n AUC (0.66) was significantly higher than the Ua cord pH AUC (0.44) (P<0.005), with the best pH euc-n cut-off value at 7.11. CONCLUSION: Despite the study limitations, our results suggest that pH euc-n is a better marker than Ua pH for predicting admission to the NICU in newborns with acidemia at birth. These are preliminary results and further investigations are mandatory in larger population samples to confirm these findings and to determine the optimal cut-off value for pH euc-n for the most accurate prediction of a complicated transition to extrauterine life and, potentially, neonatal hypoxic-ischemic encephalopathy.

Newborn brachial plexus injuries: The twisting and extension of the fetal head as contributing causes.

The exact mechanism of the causation of brachial plexus injury (BPI) has long been a matter of controversy. It is our opinion that the twisting and the extension of the fetal head, during the labour and delivery process, will increase the stretching of the neck, thus contributing to the labour forces as the cause of BPI. Our opinions are offered to other researchers and readers for their consideration of how the labour forces can cause BPI.

[Delivery in lateral position. Randomized clinical trial comparing the maternal positions in lateral position and dorsal position for the second stage of labour]. / Accouchement en décubitus latéral. Essai clinique randomisé comparant les positions maternelles en décubitus latéral et en décubitus dorsal lors de la deuxième phase du travail.

OBJECTIVE: To evaluate the influence of a maternal position for childbearing, that of lateral decubitus compared with the dorsal decubitus in second phase of parturition, by studying various parameters such as: rate of intact perineum, electronic foetal heart rate monitoring during expulsion, mode of delivery, quantity of maternal blood losses, and neonatal status. PATIENTS AND METHODS: The type of study was as follows: prospective, comparative and randomized according to Zelen's design, monocentric, in pragmatic mode and intention to treat. After a review of the literature and a retrospective analysis of the activity of a service (Romans-sur-Isère/France), an assumption of improvement of 15% of the rates of intact perineum in lateral position is put forth. An amount of 562 patients was included and randomized in 2 groups in which the childbirth was carried out in dorsal or lateral decubitus. The data were analysed by software SPSS version 13, by using the tests t of Student, Chi(2) of Pearson or the exact test of Fisher. The analysis relates to 487 patients after exclusion of the distortions to the protocol. RESULTS: We observed a significant increase in the rate of intact perineum, as well as a significant increase in the maternal blood loss, without exceeding the physiological limits, during expulsion in lateral position. The rate of directed delivery was less but more frequent were the haemorrhages in decubitus side. The rate of artificial delivery and/or uterine revision doubled without however reaching the threshold of significativity. Finally, the other parameters did not differ between the two groups. DISCUSSION AND CONCLUSION: The test makes it possible to show the improvement of the perineal status during dorsal childbirth in decubitus side compared with the position in decubitus. The data collected prove to be in conformity with those of the literature, which is not very prolix on the subject! The secondary criteria are not improved, and professionals must carry out a reflexion concerning delivery, to adapt the recommendations for the introduction of such practice into a service, must carry out a reflexion. This study provides the scientific basis (NP1), which makes it possible to justify the diffusion of this position of expulsion if one is keen on the improvement of the perineal status.

Neonatal metabolic acidosis at birth: In search of a reliable marker.

OBJECTIVE: A newborn may present acidemia on the umbilical artery blood which can result from respiratory acidosis or metabolic acidosis or be of mixed origin. Currently, in the absence of a satisfactory definition, the challenge is to determine the most accurate marker for metabolic acidosis, which can be deleterious for the neonate. METHODS: We reviewed the methodological and physiological aspects of the perinatal literature to search for the best marker of NMA. RESULTS: Base deficit and pH have been criticized as the standard criteria to predict outcome. The proposed threshold of pathogenicity is not based on convincing studies. The algorithms of various blood gas analyzers differ and do not take into account the specific neonatal acid-base profile. CONCLUSION: Birth-related neonatal eucapnic pH is described as the most pertinent marker of NMA at birth. The various means of calculating this value and the level below which it seems to play a possible pathogenic role are presented.

[Neonatal eucapnic pH at birth: Application in a cohort of 5392 neonates]. / Le pH eucapnique néonatal à la naissance : application à une cohorte de 5392 nouveau-nés.

OBJECTIVE: To apply a newly concept of neonatal eucapnic pH at birth [pH euc (n)] and compare its contribution towards conventional criteria of severe metabolic acidosis. METHODS: Analysis of a cohort of 5392 neonates from 2010 to 2014 in a level 1 maternity. clinical data (birth weight, gestational age, mode of delivery, APGAR score) were collected from archived files. Biological data were collected from umbilical cord blood, consisting of pH, PCO2, Base deficit, lactate. Eucapnic pH and eucapnic base deficit were calculated from pH and PCO2 with the Henderson-Hasselbalch equation applied in the Charles-Racinet diagram and/or with an Excel spreadsheet. RESULTS: Data set the prevalence of neonatal acidemia<7.00 to 0.62 %. The current cohort shows 32 cases of severe neonatal metabolic acidosis according to ACOG-AAP (2014) criteria and 26/29 cases according to McLennan (2015) criteria, of which 80 % were born by cesarean section or instrumental delivery. In 55 % of cases, calculated eucapnic pH at birth did not confirm the severity of metabolic acidosis based on a threshold set at 7.11. Five cases were transferred in neonatalogy only on clinical considerations of poor neonatal adaptation but not on biological consideration (pH euc<7.11 was equally distributed between transferred and non-transferred neonates, P=0.76; the same distribution was observed with the pH, P=0.20) and followed normal outcome. DISCUSSION AND CONCLUSION: The pH determination provides information only on the degree of acidemia and not on respiratory and/or metabolic components. Moreover, hypercapnia always present at birth is not included in the instructions to determine a metabolic acidosis (The American College of Obstetricians and Gynecologists, 2014; MacLennan et al., 2015). The new concept of neonatal eucapnic pH at birth accounts for only the metabolic component. We feel it should fine tune indications for cerebral hypothermia and thus improve its effectiveness. From a medicolegal perspective, for cases of cerebral palsy, it often allows to refute metabolic acidosis in perpartum events, often wrongfully being linked to generate cerebral injuries.

[Maternal posture during parturition]. / Positions maternelles pour l'accouchement.

Human parturition is a painful and sometimes dangerous physiologic process, which has been managed all over the time through mobilisation and various maternal vertical postures. Three hundred years ago, Mauriceau, a French obstetrician, imposed a semi-recumbent position for the second stage of labor, which became largely adopted in western countries. For three decades, spontaneous positions for parturition have been encouraged, based on anatomophysiologic considerations. There is now sufficient data from randomised trials for recommending maternal mobility during labor and various vertical positions for delivery. Yet, the third stage is sometimes more hemorrhagic and should be managed through preventive measures.

[Can caesarean delivery prevent cerebral palsy? Medico-legal implications of a French ecological study]. / La césarienne peut-elle prévenir la paralysie cérébrale ? Implications médico-légales d'une étude écologique française.

OBJECTIVE: For a long time, the benefit of a caesarean delivery in the prevention of cerebral palsy (CP) has been put forward, which was based on the assumption that CP is due to asphyxia in more than 50 % of the cases. However, from register-based data, this rate has been estimated less than 4 %. The aim of this study was to evaluate whether the rate of caesarean sections for fetal indication was correlated with the prevalence rate of CP in a French county. PATIENTS AND METHODS: This was an ecological study of register-based prevalence estimates of children with CP (postnatal cases excluded) born between 1997 and 2003 in a French county compared with the rates of caesarean section for fetal distress obtained from the maternal and infant protection service of the county. RESULTS: Whilst the rate of caesarean section for fetal indication increased by 44% during the period studied, the prevalence of CP remained nearly stable around 1.5 per 1000 live births. There was no correlation between caesarean section and CP prevalence (r'=-0.36, P=0.43). DISCUSSION AND CONCLUSION: The present study was in accordance with the results of a recent meta-analysis which concluded that emergency and prophylactic caesarean deliveries were not efficient in the prevention of CP. Indication of caesarean delivery for foetal heart rhythm anomaly, which is the most relevant cause for the growing rate of caesarean sections, should be justified by additional examinations in ambivalent cases, in order not to consider it as defensive medicine, which is ethically and therefore juridically blameworthy.

Detection of Toxoplasma gondii in 94 placentae from infected women by polymerase chain reaction, in vivo, and in vitro cultures.

The biological diagnosis of congenital toxoplasmosis at birth is important to determine the infant's treatment. The aim of this study was to evaluate the placenta results in the congenital toxoplasmosis diagnosis and to compare them with those obtained with other samples collected at birth (cord blood and newborn blood). A total of 94 placentas, of which 33 came from fetuses suspected of or with proven congenital toxoplasmosis (CT+) and 61 from definitely or probably non-infected fetuses (CT-), was analysed by in vitro culture, mouse inoculation and polymerase chain reaction (PCR). The PCR sensitivity was higher (60.9 per cent) than that of cell culture (29.6 per cent) and mouse inoculation (51.5 per cent) but the number of PCR positive results in CT - patients was also higher (9.5 per cent). The presence of Toxoplasma gondii in the placenta tissues was the only argument at birth (IgM and neosynthesized Ig were negative) in three out of the 33 CT+ cases. The detection of IgM by ELISA and ISAGA and the detection of neosynthesized Ig by immunoblotting were more satisfactory to diagnose congenital toxoplasmosis but the placenta analysis was important to improve the sensitivity of the diagnosis at birth, especially when the prenatal diagnosis was negative or not performed.

Tubal sterilization by a combined laparoscopic and external technique: preliminary report on 75 cases.

A preliminary report is given on a new laparoscopic sterilization procedure. By a double-puncture method, a loop of tube is brought out of the abdomen through the suprapubic incision. The loop is then resected by a modified Pomeroy method. Between Octorber 1976 and June 1978, 75 sterilizations were performed without any major problem. Sterilization failed in one case when one tube could not be seen. All recoveries were uneventful. Safety, effectiveness, simplicity, and potential reversibility seem to be the qualities of this method.

[Evaluation of perineal comfort following delivery in primiparae]. / Evaluation du confort périnéal en suites de couches chez les primipares.

The authors followed a population of 204 primiparous women in order to be able to tackle the causes of those frequent sexual problems that occur after delivery. Obstetric perineal lesions were found in 46 cases of left lateral episiotomies, 104 cases of midline episiotomies and 54 cases where the perineum was said to be intact. Following delivery at the Maternity Unit, those patients who had a perineal incision suffered more without any difference whether the episiotomy was a midline or a lateral one. After a mean of 78 days following delivery, at the post-partum examination, sexual troubles were found to be frequent and 41% complained of dyspareunia. These troubles were scattered in all three series. There was no difference whether the mother was breast-feeding or not in relationship to her sexuality after delivery. The authors conclude that there is no proper correlation between the way the perineum was dealth with surgically and the quality of sexual activity experienced early after delivery.

[An original model of experimental endometriosis in the rabbit]. / Modèle original d'endométriose expérimentale chez la lapine.

An attempt to create experimental endometriosis in the rabbit by the usual technique was tried on eight animals. It was disappointing. A new technique which is easier to carry out implanting endometrium was suggested. The results were evaluated in 57 animals. The technique proved to be easier and more reliable. The technique cannot be used unless the animal has been through puberty.

[Complete and complicated tears of the perineum in spite of preventive incision. A study of the risk factors and the short-term consequences]. / La déchirure complète et compliquée du périnée malgré incision prophylactique. Etude des facteurs de risque et des conséquences à court terme.

A retrospective study of case controls was carried out by postal enquiry to find out the risk factors for complete complicated tears (DCC) of the perineum occurring after prophylactic episiotomy. There were 33 such cases of DCC out of 8,039 vaginal deliveries which means 0.41% in the University Centre in Grenoble in the years 1985-1986-1987. A control group of 66 cases was paired according to parity and episiotomy. The risk factors were identified as large fetal weight, instrumental deliveries, mid-line episiotomy or perineotomy. The questionnaires could be analysed for faults after delivery in 26 cases and 52 controls (response rate of 90%). The sole significant problem of the cases was perineal and rectal pain lasting more than a month longer than in the control cases. There was no greater dyspareunia, stress incontinence with urine, nor anal incontinence which contradicts previous reports in the literature. The authors conclude there are no serious complications of DCC following perineotomy providing repair is carried out very carefully. The patients in this group show that is was acceptable because no more in this group than in the controls were frightened of a repeat pregnancy.

[Forceps at a university hospital. Critical study of the evolution of the procedure]. / Le forceps en hôpital universitaire. Etude critique de l'évolution de la pratique.

A retrospective study was carried out using the obstetric summaries in a computer between the years 1981 and 1986. The percentage of instrumental deliveries using forceps or spatula was significantly reduced whereas the caesarean section rate stayed the same: the majority of forceps deliveries during the year 1986 (14.5% of all deliveries) were carried out under epidural analgesia (70% of the deliveries) and the mean of these (75%) were carried out for delay. This is a definite change as compared with 1981 and it appears to be linked mainly to an increase in the number of epidural analgesics (70% for forceps deliveries in 1986) and a new appreciation of fetal distress. The maternal results were better because most episiotomies were lateral (60% of cases) which meant that only 1.5% of cases affected the sphincters. The immediate neonatal results were good, but do not seem to have been improved by the changes that have been observed, although the methodology for assessing the state of the neonate has improved.

[Labor in the squatting position. [A randomized trial comparing the squatting position with the classical position for the expulsion phase]. / L'accouchement en position accroupie. Essai randomisé comparant la position accroupie à la position classique en phase d'expulsion.

OBJECTIVE OF STUDY: To evaluate the influence of a vertical delivery position squatting during expulsion, studying different parameters such as duration of expulsion, neonatal status, delivery mode, frequency of hemorrhagia, perineum status and patient comfort. TYPE OF STUDY: Randomized, unicentric, comparative, open, prospective. MATERIAL AND METHOD: After a retrospective study determining feasibility, 240 patients were randomized to equal 2 groups in which the delivery was performed in squat position versus in lithotomy position. All the above described parameters were recorded and treated by the Epi-Info software package using Student t test, chi 2 and Kruskall-Wallis test. RESULTS: Our study has shown a tendency to shorten the length of the expulsion phase and a reduced use of forceps in the squat position. This is consistent with other studies published in the literature. We would like to emphasize that even if it does not show a medical advantage on the studied parameters, the squat position is not deleterious and can provide a better comfort for the patients who want to use it.

[Indication and technic of tubal sterilization by vaginal route. Posterior transverse colpotomy]. / Indication et technique de la stérilisation tubaire par voie vaginale. Colpotomie transversale postérieure.

40 tubal sterilisations have been carried out in 5 years. The indications most often are for grand parity. The anatomical criteria for effective sterilisation by the vaginal route should be sought by gynaecological examination under general anaesthetic. The date for the operation, the technique and its difficulties have been described. The operation lasted on an average 30 minutes. The average stay in hospital was 8.2 days. Only one local complication using this techinque was noted. On one occasion the authors had to abandon the vaginal route to reach the tubes. This simple procedure without any aesthetic inconvenience seems to them to be the ideal route for tubal sterilisation.

[Indications of radio-pelvimetry at a university hospital and a district general hospital]. / Indications de la radiopelvimétrie en hôpital universitaire et en hôpital de troisième catégorie.

Studies carried out on the phantom have shown how reliable transverse diameter measurements of the pelvis are when carried out by X-Ray scanning pelvimetry compared with conventional X-Ray pelvimetry. The practice of scanning radiopelvimetry (digital radiography) depends on the availability of the machine and of an induced, secondary circuit. The arrival of this new technique makes it necessary for the sake of economy to limit the indications for the investigation. We have studied the indications for the examination in a population of pregnant women in a University Hospital Service as well as pregnant women in a District General Hospital. Since the conditions under which obstetrics are carried out in general hospitals are more precarious, more radiological examinations are carried out in them. Frequently investigations were carried out on primiparous women who have normal pelves. It appeared difficult to lower the number of indications. Digital X-Rays will therefore cost a lot. In university hospitals the indications for carrying out the investigations were studied critically. It seems to be possible to reduce the numbers to 6% of all patients who are delivered. Rationalizing the indications will make it possible to avoid the extra cost which results from carrying out scanning X-Ray pelvimetries more reliably and delivering a lesser dose of X-Rays than ordinary conventional X-Ray pelvimetries deliver.

[The value of color Doppler ultrasound in the diagnosis of breast tumors]. / Intérêt de l'échographie Doppler couleur dans l'exploration des tumeurs du sein.

A prospective study was performed in 102 patients, including 40 malignant tumors (13 subclinical), to evaluate colour Doppler in breast tumours. All patients had abnormalities that led to their selection for this study. 92 patients had a mammographic examination. 10% of malignant tumours were not detected by mammography. Mammographic abnormalities without any ultrasonographic confirmation were excluded from this series. All the lesions have been proven by cytology or histology. In the assessment of malignancy only one false negative and two false positive results were obtained. The sensitivity and specificity of colour Doppler are both of 97% with radiate vessels beneath the tumour and intratumoral vessels as malignant criteria. This non invasive method should be performed in lesions with tissue ultrasonographic appearances even before fine needle puncture. So it may be possible to select more surgical indications considering an ultrasonographic abnormality atypical, subclinic or post-therapeutic (radiotherapy or surgery).

[Evaluation of maternal morbidity after drug-induced termination of pregnancy (TOP) after 12 gestation weeks]. / Evaluation de la morbidité maternelle après interruption médicamenteuse de grossesse à partir de 12 semaines d'aménorrhée.

OBJECTIVE: The number of TOP for medical indications has increased regularly over the last ten years. At the same time, the methods used for TOP have evolved. The purpose of this study was to assess the frequency of complications after drug-induced termination of pregnancy in order to determine whether using this method for interrupting pregnancy during the second or third trimester adds further danger for the mother in terms of early severe risk (uterine rupture, hysterectomy) or less severe long-term risk (infection). MATERIAL AND METHODS: This metaanalysis included all articles devoted to pregnancy interruption from 12 gestation weeks retrieved from the Medline database and published between 1989 and 1999 in the United States, Canada, Australia, New Zealand, or the European Union. After excluding articles that included in utero death (n=8), isolated case reports and series involving a high-risk of maternal somatic complications (n=16), and surgical methods for pregnancy termination (n=4), we retained 23 articles for analysis. These articles had included 58,891 drug-induced terminations of pregnancy. For each article, we recorded the following complications: bleeding requiring transfusion, uterine rupture, ovular or placentar retention, and infection. A classical homogenicity test was performed for each type of complication. When this test was not significant, a mean rate, weighing by size of the study, was calculated. RESULTS: One study reported maternal deaths (3/143000). The weighted mean rate for late retention (>24 hr) was 1.5 [CI95: 1.1%-1.9%]. For infections, the rates were very variable between studies (from 0.7% to 3.6% with one study reporting 8%). For bleeding with transfusion, the weighted mean rate was 0.7% [CI95: 0.5%-0.9%]. This rate was significantly higher than the rate observed in 1999 in France after delivery excepting medically terminated pregnancy (p<10(-3)) but probably is a reflection of the variable transfusion practices during the eighties in these different countries. Th rate of uterine rupture after medically terminated pregnancy was 0.1% [CI95: 0.07%-0.17%] and would be higher after delivery (excepting terminations) but not significantly (p=0.07). CONCLUSION: This metaanalysis demonstrates that the risk of severe complications (uterine rupture and bleeding requiring transfusion) are rare but are more prevalent than after delivery except pregnancy termination. The metaanalysis approach is justified due to the low incidence of these severe complications. A prospective multicentric study of the complications using a geographical base would be useful to obtain unbiased data on risk level. A risk analysis by gestational age, maternal age, parity, and product used would thus be possible, as would long-term monitoring of maternal outcome.

[Prevention of peritoneal adhesions. An experimental study using noxytiolin (author's transl)]. / Prévention de adhérences péritonéales. Etude expérimentale de la Noxytioline.

Numerous procedures have been used to try to prevent peritoneal adhesions following operations. Noxytiolin has been used experimentally in the rat in a double blind trial on 3 series of 30 rats. A reliable procedure for making adhesions is said to be always reproducible. Comparing two control groups this study shows that statistically significantly this product lessens the number and seriousness of adhesions that can form, although it does not totally stop them developing.