[Impact of prolonged second stage of labor on perinatal morbidity : what is our experience ?] / Impact d'un second stade de travail prolongé sur la morbidité périnatale : quelle est notre expérience?

OBJECTIVE: the management of the second stage of labor and its optimal duration are controversial, particularly for nulliparous women. Our aim is to analyze the impact of a prolonged second stage on perinatal morbidity in our institution. MATERIAL AND METHODS: this is a retrospective study conducted in the University Hospital of Liège (Belgium) from January to July 2019. The 160 patients included were divided into two groups according to the duration of the second stage and compared in terms of mode of delivery, maternal and neonatal morbidity. RESULTS: group 1 (85 %) had a second stage of labor inferior to 3 hours and group 2 (15 %) ? 3 hours. The cesarean deliveries for non-engagement of the fetus were significantly higher in group 2. No significant difference was observed in terms of maternal morbidity. The median Apgar score at 5 minutes was higher in group 1. The proportion of babies transferred to neonatal intensive care and to the neonatology department was higher in group 2. CONCLUSION: we mainly noted an increase in neonatal morbidity when the second stage exceeded 3 hours, which is consistent with literature where an increase in maternal morbidity is also described. Prolonging the second stage therefore seems inappropriate to us in the current state of knowledge.

OBJECTIFS: la gestion du second stade de travail et sa durée optimale sont controversées, particulièrement pour les patientes nullipares. Notre objectif est d'étudier l'impact d'un second stade prolongé sur la morbidité périnatale dans notre institution. Matériel et méthodes : il s'agit d'une étude rétrospective menée au CHU de Liège de janvier à juillet 2019. Les 160 patientes incluses ont été réparties en deux groupes en fonction de la durée du second stade et comparées en termes de mode d'accouchement, morbidité maternelle et néonatale. Résultats : le groupe 1 (85 %) présentait un second stade inf�rieur a 3 heures et le groupe 2 (15 %) ? 3 heures. Les césariennes pour non-engagement étaient significativement plus élevées dans le groupe 2. Aucune différence significative n'a été observée en termes de morbidité maternelle. Le score d'Apgar médian à 5 minutes était plus élevé dans le groupe 1. La proportion de bébés transférés au NIC («Neonatal Intensive Care¼) et en néonatologie était plus élevée dans le groupe 2. CONCLUSION: nous avons principalement noté une majoration de la morbidité néonatale lorsque le second stade dépassait 3 heures, ce qui rejoint la littérature où l'on décrit, également, une majoration de la morbidité maternelle. Prolonger le second stade nous semble, dès lors, inapproprié dans l'état actuel des connaissances.

[Maternal-fetal cytomegalovirus infection : experience in Liege and new antenatal screening and care strategy]. / Infection materno-fœtale à cytomégalovirus. Expérience liégeoise et nouvelle stratégie de dépistage et de prise en charge anténatale.

Summmary : In Belgium, as in most developed countries, routine antenatal screening for cytomegalovirus (CMV) remains controversial and is not recommended. However, 1-2 % of seronegative pregnant women will develop a primary infection during pregnancy and, with a prevalence of 0.7 % of live births, CMV is the leading cause of congenital infection. Among infected newborns, 20 to 25 % will develop auditory or neurological sequelae. The initial objective of our study was to evaluate, from a cohort of 48 patients followed in the antenatal diagnosis Unit of the University Hospital of Liège, the rates of maternal-fetal transmission, medical termination of pregnancy and rates of sequelae in infected newborns and to compare them with findings found in the literature. The second objective was to synthesize the current state of knowledge on maternal-fetal CMV infection and, in the light of recent data on prenatal treatment with valaciclovir, to propose a screening and management algorithm for primary CMV infection in the first trimester of pregnancy.

En Belgique, ainsi que dans la plupart des pays développés, le dépistage anténatal systématique du cytomégalovirus (CMV) reste controversé et n'est pas recommandé. Toutefois, 1 à 2 % des femmes enceintes séronégatives feront une primo-infection pendant la grossesse et, avec une prévalence de 0,7 % des naissances vivantes, le CMV est la première cause d'infection congénitale. Parmi les nouveau-nés infectés, 20 à 25 % développeront des séquelles auditives ou neurologiques. L'objectif initial de notre étude a été d'évaluer, à partir d'une cohorte de 48 patientes suivies dans l'Unité de diagnostic anténatal du CHU de Liège, les taux de transmission materno-fœtale, d'interruption médicale de grossesse et de séquelles chez les nouveau-nés infectés et de les comparer à ceux retrouvés dans la littérature. Le second objectif a été de synthétiser l'état actuel des connaissances sur l'infection materno-fœtale à CMV et, à la lumière des données récentes sur le traitement anténatal par valaciclovir, de proposer un algorithme de dépistage et de prise en charge de la primo-infection par le CMV au 1er trimestre de la grossesse.

[Spontaneous rupture of a splenic artery aneurysm during the third trimester of pregnancy]. / Rupture spontanée d'un anévrysme de l'artère splénique au cours du troisième trimestre de la grossesse.

We report the case of a 24-year-old female patient with spontaneous rupture of a splenic artery aneurysm in the third trimester of pregnancy. Pregnancy, throughout the physiological and hormonal changes it imposes, promotes the occurrence of aneurysm of the splenic artery and its rupture. Although this is a rare complication, its prognosis is severe and its typical clinical picture associating abdominal pain, hypotension and anemia is misleading for the clinician who likelier evokes a retroplacental hematoma or an uterine rupture. The maternal and foetal survival depends on rapid diagnosis and multidisciplinary management. Thus, it's important for the clinician to consider this differential diagnosis when abdominal pain or hemoperitoneum occurs in pregnant woman, particularly during the third trimester of pregnancy.

Nous rapportons l'histoire d'une patiente de 24 ans ayant présenté une rupture spontanée d'un anévrysme de l'artère splénique au cours du troisième trimestre de la grossesse. Celle-ci, de par les changements physiologiques et hormonaux qu'elle impose, favorise la survenue de l'anévrysme de l'artère splénique et sa rupture. Bien qu'il s'agisse d'une complication rare, son pronostic est redoutable et le tableau clinique typique associant douleur abdominale, hypotension et anémie est trompeur pour le clinicien qui évoque, plus volontiers, un hématome rétroplacentaire ou une rupture utérine. La survie materno-fœtale dépend de la rapidité diagnostique et d'une prise en charge multidisciplinaire, raisons pour lesquelles il est important que le clinicien considère ce diagnostic différentiel lors de la survenue d'une douleur abdominale ou d'un hémopéritoine chez la femme enceinte, particulièrement durant le 3ème trimestre de la grossesse.

[Elective induction of labor in nulliparous women : should we stop ?] / L'induction élective du travail chez la patiente nullipare : stop ou encore ?

In Wallonia, almost one fourth of cesarean sections are performed on nulliparous women with vertex nonanomalous singleton gestations who underwent induction of labor. The purpose of this study is to compare maternal and neonatal outcomes with elective induction of labor versus spontaneous onset of labor. Data for all deliveries at CHU de Liège over a two-year period were obtained. Women with vertex nonanomalous singleton gestations who delivered from 3900 to 40+6 weeks were selected. We tested the association of elective induction and operative vaginal delivery, cesarean section, post-partum hemorrhage, episiotomy and perineal lacerations, length of labor, length of stay, 1-min and 5-min APGAR inferior to 7 and admission to neonatal intensive care unit. Length of stay was significantly longer in all induced women. In nulliparous women, there was a 45 % probability of operative vaginal delivery or cesarean section delivery in those who underwent elective induction of labor. In light of these results, it seems that our policy of elective induction of labor in nulliparous women is causing unnecessary and potentially avoidable interventions.

En Wallonie, l'induction du travail chez les patientes nullipares avec grossesse singleton en présentation céphalique recrute près d'un quart de l'ensemble des césariennes réalisées. L'objectif de cette étude est de comparer le travail spontané et l'induction élective du travail en termes d'issues obstétricales et de morbidités maternelles et néonatales. Entre janvier 2015 et décembre 2016, les femmes ayant accouché entre 390 et 40+6 semaines d'aménorrhée (SA) au CHU de Liège et ayant présenté une grossesse singleton avec présentation céphalique, sans pathologie maternelle, gravidique ou fœtale ont été sélectionnées. Les variables suivantes ont été retenues : taux d'extraction instrumentale, taux de césarienne, type d'hémorragie du post-partum, état du périnée, durée du travail, durée d'hospitalisation, APGAR (1-5 min) défavorable (inf�rieur a 7) et passage en néonatologie. La durée d'hospitalisation est augmentée chez toutes les femmes induites. Chez les patientes nullipares, l'induction élective se solde, dans 45 % des cas, par une extraction instrumentale ou une césarienne en cours de travail. Nos pratiques d'induction élective chez les patientes nullipares pourraient être responsables d'un certain nombre d'interventions non nécessaires et évitables.

[«I am not pregnant !¼ About denial of pregnancy ]. / «Je ne suis pas enceinte !¼ A propos du déni de grossesse .

The term «denial of pregnancy¼, although used in current medical practice since 1970, does not yet have a universal definition. The literature allows to define it as «the non-recognition of a pregnancy beyond the first trimester, which can last until delivery and cover it¼. The changes related to pregnancy are biologically reduced or incorrectly perceived or even ignored. Although often wrongly considered as a rare phenomenon, the literature describes it as having a prevalence of 2 to 3 cases per 1.000 viable deliveries. This case report associated with a short review of the literature aims to optimise the clinician awareness, leading to the diagnosis as well as the potential perinatal consequences linked to this phenomenon.

Le terme de «déni de grossesse¼, bien qu'utilisé dans la pratique médicale courante depuis 1970, n'a, à ce jour, pas encore de définition universelle. La littérature permet de le définir comme la «non-reconnaissance d'une grossesse au-delà du premier trimestre, qui peut se prolonger jusqu'à l'accouchement et recouvrir ce dernier¼. Les changements liés à la grossesse sont biologiquement réduits et incorrectement perçus par la femme, ce qui fait passer son évolution sous silence. Bien que souvent considéré à tort comme un phénomène rare, la littérature le décrit, cependant, avec une prévalence de 2 à 3 cas pour 1.000 accouchements viables. Le cas clinique rapporté ici, accompagné d'une revue succincte de la littérature, vise à conscientiser les cliniciens quant aux circonstances de diagnostic d'un déni de grossesse et la morbi-mortalité périnatale qui y est, potentiellement, associée.

[The amniotic band syndrome : a rare and severe malformative pathology]. / La maladie des brides amniotiques. Une pathologie malformative rare et sévère.

Antenatal diagnosis of the amniotic band syndrome often occurs during the second trimester of pregnancy when complex and asymmetrical limb deformities are observed. As vital prognosis depends on the gravity of malformations, lesion assessment should be as accurate as possible. Color doppler US screening is useful and could unravel limb vascular compression by an amniotic band. A vascular stop predicts in utero limb amputation. We hereby report the case of a 30-year-old patient pregnant with a fœtus presenting 4-limb deformities. One limb was highly suspected of undergoing amputation. Facing those heavy-burden anomalies, the patient asked for a medical termination of her pregnancy.

Le diagnostic anténatal de la maladie des brides amniotiques est le plus souvent réalisé au deuxième trimestre de la grossesse par la mise en évidence de malformations complexes et asymétriques des membres. Comme le pronostic dépend de la gravité des malformations, un bilan lésionnel précis doit être réalisé. L'utilisation du doppler couleur permet d'évaluer la compression vasculaire par la bride au niveau des membres. L'arrêt du flux artériel semble prédictif d'une amputation du membre in utero. Nous rapportons le cas d'une patiente dont le fœtus présentait des anomalies des 4 membres avec un membre en voie d'amputation et qui, devant la gravité des lésions, a souhaité une interruption médicale de grossesse.

[Alcohol, pregnancy and breast-feeding]. / Alcool, grossesse et allaitement.

Perinatal studies over the last ten years report that 3 % of pregnant women have alcohol consumption. The malformative and neurological consequences of prenatal exposure to alcohol have been known for more than 50 years. Research has shown that the effects of alcohol during pregnancy and breast-feeding go far beyond visible abnormalities at birth. Neurological consequences, from minor psychomotor retardation to severe behavioural disorders, make all the severity of this intoxication and justify strict instructions to refrain from taking alcohol during pregnancy and breast-feeding.

Les enquêtes périnatales réalisées au cours des dix dernières années rapportent que 3 % des femmes enceintes consomment de l'alcool. Les conséquences malformatives et neurologiques de l'exposition prénatale à l'alcool sont pourtant connues depuis plus de 50 ans et l'avancée des recherches a montré que les effets de l'alcool durant la grossesse et l'allaitement vont bien au-delà d'anomalies visibles à la naissance. Les conséquences neurologiques, du retard mineur aux troubles comportementaux sévères, illustrent toute la gravité de cette intoxication. Ils justifient une consigne stricte d'abstention de consommation d'alcool durant la grossesse et l'allaitement.

[Delivery site for fœtus with congenital heart disease : CHU of Liège experience and international recommandations]. / Choix du lieu de naissance du fœtus cardiopathe. Expérience liégeoise et recommandations internationales.

Optimal choice of delivery site after a diagnosis of congenital heart disease (CHD) improves neonatal mortality and morbidity. We report the CHU of Liège experience and review the international recommendations. Between 2011 and 2016, 54 fetuses were diagnosed with CHD in our service. Retrospectively we estimated the appropriateness of the site of delivery considering the postnatal outcome. We confronted our experience with the recent international recommendations for in utero transfer to a tertiary center. The latter are based on the risk of hemodynamic instability at birth but differ for the ductal-dependent cardiopathy. The postanatal evolution and the low emergency transfer rate (4 %) in our series demonstrate the quality of our policy. We propose to validate the French transfer in utero recommendations for our obstetrical department, especially for ductal-dependent cardiopathy.

Le choix d'une structure de naissance adaptée au foetus cardiopathe permet de diminuer la morbi-mortalité néonatale. Nous rapportons l'expérience du CHU de Liège en matière d'orientation obstétricale des foetus cardiopathes et la confrontons aux données internationales. De 2011 à 2016, 54 fœtus cardiopathes ont été examinés dans notre unité de diagnostic anténatal. Cette série fait l'objet d'une analyse rétrospective en termes de pertinence du choix du lieu de naissance au vu de l'évolution postnatale et d'une confrontation aux recommandations internationales récentes de transfert in utero. Ces dernières reposent sur le risque d'instabilité néonatale et diffèrent pour les cardiopathies ducto-dépendantes. L'évolution néonatale et le faible taux de transfert postnatal urgent (4 %) dans notre série témoignent d'une orientation obstétricale adaptée. Nous proposons d'implémenter, au sein du département obstétrical universitaire liégeois, les recommandations françaises de transfert in utero en centre tertiaire, notamment le transfert des cardiopathies ducto-dépendantes.

[Hematocolpos : an unappreciated diagnosis of hymen imperforation]. / Le cas clinique du mois. Hématocolpos : un diagnostic méconnu d'imperforation hyménéale.

The imperforation of the hymen is a relatively rare congenital malformation. It usually manifests itself in adolescence by a hematocolpos. Hematocolpos is the vaginal retention of menstrual blood at puberty. It results clinically in painful amenorrhea and more rarely in a pelvic mass syndrome. The diagnosis is easy, it is primarily clinical. Pelvic ultrasound and nuclear magnetic resonance are the complementary examinations to be performed as a preoperative assessment and to detect any associated genito-urinary malformations.

L'imperforation de l'hymen est une malformation congénitale relativement rare. L'hématocolpos, qui désigne l'accumulation progressive de sang menstruel dans la cavité vaginale, en est la manifestation la plus fréquente à l'adolescence. Il se traduit cliniquement par une cryptoménorrhée douloureuse et, plus rarement, par un syndrome de masse pelvien. Le diagnostic est facile et, avant tout, clinique. L'échographie et la résonance magnétique nucléaire sont les examens complémentaires de choix pour déceler d'éventuelles malformations génito-urinaires associées. Le traitement consiste en une hyménéotomie.

[A case of fetal death resulting from a massive fetomaternal hemorrhage]. / LE CAS CLINIQUE DU MOIS. Mort foetale in utero due à une hémorragie foeto-maternelle massive.

We report the case of a late stillbirth which unexpectedly occurred in a patient without any medical history and after a meticulous obstetrical follow up. Stillbirth is unfortunately not unusual and implies a complete etiological work up. In the present observation, the Kleihauer test and anatomoclinical examination concluded that the death was due to an acute cerebral anoxy resulting from a massive fetomaternal hemorrhage (HFM). HFM is rarely considered as the cause of a late stillbirth, but its occurrence is certainly underestimated. Yet, if HFM is identified before fetal death, an .adequate management could considerably improve the fetal prognosis and, sometines, save the child's life.

[Clinical case of the month. Unfavourable outcome of a triplet gestation]. / Issue d favorable d'une grossesse triple.

Body stalk anomaly is rarely described in triplet gestation after medically assisted procreation. The relationship between congenital anomaly, multiple pregnancy, and medically assisted procreation is briefly discussed.

Variation of the maximum velocity along the umbilical vein supports the Reynolds pulsometer model.

OBJECTIVE: To challenge, with a modern sonographic approach and a numerical model, the Reynolds's concept which suggests that the vascular structure of the umbilical cord could act as a pulsometer facilitating the venous return to the foetus. METHOD: Forty-five patients between 20 and 28 weeks of gestation were included in the study. The blood maximum velocity in the umbilical vein, measured at both foetal and placental ends, was assessed. Several sonographic parameters of the cord, including the diameter of the umbilical vein at both extremities, cord cross-sectional area and Wharton's jelly section surface were measured. We compare our data with those of a numerical model. RESULTS: A difference in maximum velocity between the two extremities of the umbilical vein (ΔUVVmax) was noted. The maximum velocity was significantly higher at the foetal umbilical end (14.12 +/-3.18 cm/s) than at the placental end (11.93 +/-2.55 cm/s; p < 0.0001). The mean difference is 2.2 +/- 2.3 cm/s. No difference in the umbilical vein diameter was measured at both cord ends (umbilical 4.85 +/-0.9 mm, placental 4.86 +/-0.87 mm, p < 0.0001). There is no significant relationship between ΔUVVmax and the cord cross-sectional area or Wharton's jelly index. CONCLUSION: Modifications of the spatial velocity profile together with the pulsometer model could explain the maximum velocity changes that is measured in the umbilical vein along the cord. This numerical model consolidates the sonographic observations.

[A rare case of placental chorioangioma associated with neonatal disseminated hemangiomatosis]. / Association rare d'un choriangiome et d'une hémangiomatose néonatale diffuse.

Placental chorioangioma is a benign vascular tumor. Lesions larger than 4 cm may cause fetal and maternal complications. Its association with disseminated neonatal hemangiomatosis is rarely described. We report a case of a large chorioangioma associated with an hydrops foetalis and disseminated neonatal hemangiomatosis. The relationship between placental chorioangioma and hemangioma is briefly discussed.

[New methods of prenatal screening for trisomy 21]. / Nouvelles méthodes d'évaluation du risque de trisomie 21 en consultation prénatale.

Down syndrome is the most commonly recognized genetic cause of mental retardation. The risk of trisomy 21 is directly related to maternal age which can be viewed as the first screening test in the 1970's. New strategies for Down syndrom, have emerged with higher sensitivity and lower false-positive rate. These strategies are based on sonographic and maternal serum markers. The most specific but complex strategy is based on the integrated test, i.e., the integration of the quadruple test performed in the second trimester to the first trimester combined screening: for a 85% detection rate, the false positive rate is estimated to 0.9%. This strategy deprives the patient of an early diagnosis. Alternatives strategies do exist which can perform similar detection rate but with increasing false positive rate. To date Down syndrom, screening has not been coordinated by a national body; it would be usefull to ensure the sonographist formation, perform quality audit and decrease variations in practice.

[Prenatal care and postnatal outcome for fetuses with laparoschisis]. / Gestion anténatale et issue postnatale des foetus atteints de laparoschisis.

OBJECTIVES: To assess the relevance and the quality of gastroschisis's care in a mid level referral centre. METHOD: A retrospective analysis was performed for infants diagnosed or born with gastroschisis between 1992 and 2003 at the Citadelle hospital, Department of Obstetrics and Gynaecology, University of Liège. RESULTS: Twenty-four cases of gastroschisis were identified. For 22 of them (92%) antenatal sonographic diagnosis was performed at a mean gestational age of 23 weeks. Antenatal diagnosis did not allow to identify additional malformation or chromosomal anomaly. Postnatal diagnosis allows to identify 3 infants with minor cardiac anomalies without functional consequence and one X fragile syndrome. One pregnancy was electively terminated at 24 weeks and one late intrauterine death was reported at 35 weeks. Bowel atresia, stenosis or ischemia were present at birth for 8 cases (33%). Out of 24 cases 22 were live born. 10 infants out of 22 (45%) underwent uncomplicated primary surgical repair. Three infants out of 22 (14%) underwent delayed closure without complications. Nine infants out 22 (41%) underwent multiple surgery (2 to 6). In this group all had postnatal complications, some with multisystem complications, including 3 deaths, 6 with infectious complications, 5 with gastrointestinal complications and 2 with genitourinary or haematological complications. Hospital stay range from 19 to 378 days (median, 51 days). Length of stay and time to full enteral feeding were longer if oligohydramnios or sonographic signs of intestinal damage were found. Among infants born before 35 weeks, only those with intestinal damage at birth had length of stay or time to full enteral feeding longer. Out of 22 live born infants 19 survived (86%) after one year. Survival rate without handicap due to gastroschisis is 84%. CONCLUSION: Sonographic examination is a valid method for prenatal diagnosis and surveillance. Our survival rate agrees with recent data in the literature. It has to be noticed that hospital stay is lengthy and complications are frequent. The most important prognostic factor is the condition of the bowel at birth and there is no antenatal means to predict severe damage.

Prenatal diagnosis of a terminal chromosome 1 (q42-q44) deletion: original case report and review of the literature.

Terminal chromosome 1q deletion is rarely reported but causes typical malformations that have been well described in childhood. Clinical features include facial dysmorphy, growth and/or psychomotor retardation, brain agenesis or hypoplasia of the corpus callosum, epilepsy and occasional urogenital or cardiac malformations. The diagnosis of this condition is usually made at birth. The rare cases of antenatal diagnosis were based on microcephaly and growth retardation. In the present case, the foetus presented with an hypoplasia of the corpus callosum, a dysmorphic profile and a single umbilical artery. The foetal echocardiography suggested a non- compaction of the left ventricular myocardium. No microcephaly or growth retardation were noted. We compare our antenatal findings to those described in the literature with the aim to better define the antenatal phenotype of the terminal chromosome 1 deletion syndrome.