[Postpartum urinary retention]. / Rétention vésicale du post-partum.

Postpartum urinary retention is an uncommon event that occurs in 0.7 to 0.9% of vaginal deliveries. An ignorance of this situation can lead to delayed diagnosis worsening the prognosis and to inadequate treatments. This complication is defined as the absence of spontaneous micturition within 6hours of vaginal delivery with a bladder volume above 400mL. The etiology depends on multiple factors. Because of physiological changes during pregnancy, the bladder is hypotonic with an increased post-void residual volume. The occurrence of a perineal neuropathy during delivery may cause a urinary retention. Risk factors are primiparity, prolonged labour, instrumental delivery and perineal lacerations. Treatment consists on clean intermittent catheterization and recovery occurs generally in 72hours. Persistent urinary retention is the principal short-term complication and should be treated by clean intermittent self-catheterization. Long-term consequences are poorly reported in the literature.

[Pregnant women and smoking: descriptive study and prognostic factors to stop smoking during pregnancy]. / Le tabagisme gravidique. Etude descriptive et facteurs pronostiques d'arrêt du tabac pendant la grossesse.

UNLABELLED: Nicotine addiction (NA) is a serious public health problem. Today, smoking effects on the foetus and the mother are well known; however, studies into smoker's behaviour are lacking. The aim of our paper was to identify factors which influence either NA stopping or continuation during pregnancy. METHODS: It's a descriptive study, using a questionnaire, among pregnant women during prenatal consultation in a university hospital, at home with freelance mid-wives or in mother and infant welfare services (PMI). RESULTS: Two hundred and forty-one questionnaires were analysed. Smoker's behaviour, psycho-environmental factors, co-addictions, were described and compared. One out of four women was smoking during pregnancy and one out of ten was smoking more than 10cigarettes per day. One out of three women who were smokers before pregnancy, stated that they had stopped NA during the year. Only 58/241 readings of exhaled carbon monoxide were performed, which reflects hesitation of medical staff to employ this device. Forty seven women indicated the number of alcohol glasses consumed during pregnancy. The study showed that partner's attitude towards smoking, good or bad mood during pregnancy, number of cigarettes smoked before pregnancy and medical information would appear to be significant factors that influence NA stopping during pregnancy. CONCLUSION: The identification of prognostic factors for NA stopping is of primordial importance, especially among heavy smokers, in order to target the actions necessary to help NA stopping.

[Two observations of evisceration after caesarean section performed according the so-called Stark procedure]. / A propos de deux observations d'éviscération après césariennes réalisées selon la technique de Stark.

Two cases of evisceration after caesarean sections performed according the Misgav Ladach General Hospital procedure (Stark's procedure) are reported. In these cases, omentum was sutured between the edges of fascia recti, creating a weakness of the abdominal sheath. These cases claim about a strict procedure for fascia suture. Also, these cases question about the parietal peritoneal closure and the drawing of rectus muscles, which are vertical breaks; so, these sutures close transversal incision of the abdominal wall with cross sutures, which are very secure.

[Indications and prerequisites for operative vaginal delivery: when, how and where?]. / Indications et prérequis à la réalisation d'une extraction instrumentale : quand, comment et où ?

OBJECTIVE: To determine the indications and prerequisites for operative vaginal delivery. METHODS: Articles were searched using PubMed and Cochrane library. RESULTS: Indications for operative vaginal delivery are non-reassuring fetal status (NP4), no progress from 30minutes of adequate active pushing, maternal exhaustion (NP5), or medical indications to avoid Valsalva (NP5). Operative vaginal delivery (Thierry's spatulas, forceps, and vacuum delivery) before that cervix is fully dilated and fetal head is fully engaged is not recommended (NP4). Obstetricians have to know patient medical record and the fetal head position before performing operative vaginal delivery (NP5). The reliability of transvaginal examination to determine the fetal engagement and intrapartum fetal head position is 88% and 80% respectively (NP2). Transabdominal ultrasound assessment is recommended in cases of doubts about the fetal head position (NP5). Available data are not sufficient to fully contraindicated midpelvic operative delivery. Each case should be considered individually and depending on the skill of the obstetrician (NP5). Obstetricians should be aware that they may wrongly consider the fetus engaged in the midpelvis in 6% of cases, whereas it is not really engaged. Moreover, the presence of factors predictive of failed operative vaginal delivery must contraindicated midpelvic operative vaginal delivery and indicated a cesarean delivery (NP5). In general, midpelvic operative vaginal delivery is not recommended. Routine instrumental delivery in theatre and episiotomy for operative vaginal delivery are not recommended (NP3 and NP4, respectively). CONCLUSIONS: Recommendations for operative vaginal delivery should be respected to minimize both fetal and maternal trauma. Obstetricians should anticipate the complications that may occurred following operative vaginal delivery.

[Information in perinatal medicine: ethical aspects]. / L'information dans le contexte du soin périnatal: aspects éthiques.

Besides the undeniable need to respect parental autonomy, providing information is a legal and moral obligation, to be informed a basic right. The act of informing should be considered as an exchange and necessarily begins by listening to the other. According to the jurisprudence of the Court of Cassation that draws on Article 35 of the Deontological Code, information has to be clear (implying an educational effort, availability and to check that the information has been well understood), appropriate (adapted to each situation and person) and honest (which supposes a moral contract between parents and physicians). Loyalty implies a consideration of the uncertainty underlying medical practice, and of the limitations in arriving at a prognosis. Indeed, caution needs to be exercised in conveying information, taking into account the risk of its becoming self-fulfilling, which could modify the way in which parents take care of their child. The information given has to be coherent, both within the spatial dimension (coherence of information between the different maternity services in the perinatal network) and the temporal dimension (coherence of information between pre- and postnatal stages). It must be acknowledged that information is essentially subjective. There is a fundamental difference between coherence and uniformity, and as regards information, uniformity is neither possible nor desirable. In each situation, priority must be given to oral information delivered in an appropriate material context. The principle of establishing, in the medical file, a written trace of the information given at various stages is one way to guarantee its coherence.

[The fundal height measurements in single pregnancies and the detection of fetal growth retardation]. / La mesure de la hauteur utérine dans les grossesses uniques et le dépistage des retards de croissance intra-utérins.

Symphysis fundus measurements are a reliable mean for screening of fetal growth retardation. The techniques of the measurements, the curves of normality, and the efficiency of this method are discussed. A single formula is put forward to identify the patients witch can profit by extra ultrasound examinations and special clinical surveillance. In France, ultrasound examinations are scheduled at 22 and 32 weeks. Between 22 and 32 weeks, and after 32 weeks, symphysis fundus measurements are needed to suspect intra uterine fetal retardation, and, following suspicion, a new ultrasound examination is helpful.

[Postpartum contraception: medical guidelines, women's point of view]. / La contraception du post-partum: les recommandations médicales, le point de vue des femmes.

PURPOSE: Postpartum contraception is subjected to specific medical guidelines related to the suckling mode. The practitioner must conciliate prescription rules with women's expectations. The purpose of this work was to estimate the medical practice in the maternity centre at a local hospital and the actual practice of women at home, in immediate postpartum and during the year that followed the childbirth. METHOD: One hundred and four new mothers from the maternity centre, in September 2004, took the survey. During their stay after birth, they filled a questionnaire on contraception. Various data have been collected from their obstetrical file. The analysis allowed the synthesis of medical guidelines on postpartum contraception. One year later, patients answered a telephone survey about their contraceptive practice. RESULTS: In our survey, two-third of the new mothers (61.5%) chose breast-feeding. Seventy percent of them received progestins as contraceptives. Three out of four women (78%) followed this prescription after they left the hospital. Two-third (62.5%) of the women who had chosen artificial suckling received a prescription of estroprogestin. The majority of them (96%) used it after their return home. A high number of women (87.5%) estimated that these contraceptions were efficient, but more than a third of them thought they were uneasy to use (38.9%). Half of the women (52.8%) forgot their contraception during postpartum and the majority of them (86%) changed it within a year. A quarter (23.1%) of the contraception follow-up during this time was made by a general practitioner. CONCLUSION: The practice in the maternity centre generally follows medical guidelines. However, it seems important to adapt postpartum contraception to the real practice of women. The general practitioner plays a major role in this management, especially during well-baby visits.

Inhibition by sodium thiophosphate and L-p-bromotetramisole of neutrophil alkaline phosphatase in normal and trisomy 21 pregnancies.

Alkaline phosphatase concentrations are known to increase in blood neutrophils of normal pregnant women. The main kinetic parameters of this enzyme were analysed and compared in a group of 30 women with normal pregnancies and a group of 11 women whose fetuses had trisomy 21 (Down's syndrome = DS). The subjects were studied at an identical stage of gestation. Significant changes occurred in thermal stability and urea resistance in cases of DS pregnancies. We also investigated the inactivation constants for two chemicals: L-p-bromotetramisole, an uncompetitive inhibitor, and sodium thiophosphate, a competitive inhibitor. Ki measured for the two inhibitors were found to be significantly lower in cases of pathological pregnancies. The patterns observed in inhibition constants extend the biochemical characteristics of the atypical isoenzyme expressed in neutrophils of women with DS pregnancies.

Platelet production time, uricemia, and some hemostasis tests in pre-eclampsia.

In order to choose the best adapted test for pre-eclampsia monitoring, platelet production time (PPT) was measured simultaneously with uricemia, factor VIII complex, beta-thrombogobulin, and other tests of platelet activation including platelet volume, density and platelet very dense body content. In the pre-eclamptic group (11 patients). In the PPT was significantly reduced in comparison with normal pregnancies (6 patients). In the pre-eclamptic group, there was good and significant correlation between PPT and the VIIIrAg/VIIIc ration (r = 0.87) and between PPT and uricemia (r = 0.79). The correlations between PPT and the other tests are poor and non-significant. Thus, for clinical purposes, the VIIIrAg/VIIIc ratio and uricemia are convenient parameters, and give very reliable information on the severity of the consumption coagulopathy which characterizes pre-eclamptic pregnancies.

[Renal microscopic hematuria in rheumatoid polyarthritis]. / Hématurie microscopique d'origine rénale au cours de la polyarthrite rhumatoïde.

In a retrospective study of 162 cases of rheumatoid arthritis we found that 24 patients (14.8%) had presented with microscopic haematuria with or without proteinuria. Renal biopsy had been performed in 15 of these 24 patients. Apart from the classical lesions of extramembranous glomerulonephritis, amyloidosis and interstitial nephritis, 60% of histological results showed lesions of mesangial glomerulonephritis. These lesions seemed to be independent of maintenance treatments, but they might have been facilitated by the chronic inflammation kept going by the rheumatoid disease itself.

[Desmoid tumors of the anterior abdominal wall. Apropos of a case]. / Tumeurs desmoïdes de la paroi abdominale antérieure. A propos d'une observation.

The authors describe a case of a desmoid tumor of the anterior abdominal wall. From a review of the world literature, the main characteristics of these tumors are detailed, and the various pathophysiological hypotheses, demonstrating the necessity of exclusively surgical treatment, are presented.

[Fetal and neonatal effects of maternal treatment with angiotensin converting enzyme inhibitor]. / Effets foetaux et néonatals d'un traitement maternel par inhibiteur de l'enzyme de conversion de l'angiotensine.

BACKGROUND. Exposure of pregnant women to angiotensin converting enzyme inhibitor may have side effects on the fetus or newborn, mainly oligoamnios and impaired renal function. CASE REPORT N zero 1. A 34 year-old woman was given enalapril from the onset of her pregnancy because of hypertension from the age of 18 years. Oligoamnios was diagnosed in the fetus on gestational week 28; enalapril was then replaced by nifedipine but this drug was badly tolerated so that the woman was again given enalapril 8 days later. The baby (1700 g) was born by cesarean section at gestational week 34 because of acute distress syndrome; he developed hypotension, anuria, generalized oedema and was placed in intensive care. Treatment included ventilation, sympathomimetic agents, and diuretics. An exchange-transfusion followed by peritoneal dialysis was performed a few hours later. Renal function returned to normal between the 3rd and 5th day. Unilateral kidney hypoplasia was diagnosed at the age of 2 years. CASE N zero 2. A 24 year-old woman was given enalapril at the third trimester of a twin pregnancy. Delivery was full term at 37 weeks. The first baby, a boy weighing 2610 g, suffered from hypoglycemia and vomiting followed by hypotension and oliguria that required exchange-transfusion and repeated peritoneal dialysis. This boy has developed moderate chronic renal failure and hypertension. The second baby, a girl weighing 2,165 g, suffered from respiratory distress syndrome followed by hypotension and oliguria, but her renal function returned to normal within a few days. CONCLUSIONS. The use of angiotension converting enzyme inhibitor by pregnant women places the fetus at severe risk: treatment with this type of drug should be stopped as soon as pregnancy is confirmed.

[MRI in subacromial pathology. Report of 20 cases]. / IRM dans la pathologie sous-acromiale. A propos de 20 observations.

The authors report the results of MRI performed in 20 patients presenting clinical symptoms of subacromial pathology. The MRI results are correlated to the results of arthrography or arthro CT scan and also to surgical results. MRI is an excellent technique if a precise protocol with T2 weighted images is respected in order to visualize tears or minor perforations of the supraspinatus muscle.

[Pregnancy and paraplegia. Management. A case report]. / Grossesse et paraplégie. Conduite à tenir. A propos d'un cas.

The authors report a case of pregnancy in a paraplegic patients whose lesion was at the level of T4. The patient showed minimal respiratory problems with a "heaviness" of her chest and asymptomatic urinary tract infections which did not affect fetal development. She had a normal delivery. The authors, from this case, wish to point out again that pregnancy in patients with spinal cord trauma are bedevilled by urinary tract infections, anaemia, bed sores, and the danger of hyper-reflexia of the autonomic nervous system which could affect the vital functions of the mother.

[Ultrasound monitoring]. / Le suivi échographique.

Ultrasound investigation is peculiar when pregnancy is complicated by gestational diabetes. One have to study interventricular septal thickness and to predict macrosomia. Before delivery septal thickness should be under 6 mm. Estimated fetal weight (EFW) and abdominal circumference (AC) are accurate to detect macrosomia. Quite all formulas of EFW are not significantly different. An EFW of 4,000 gm have a sensitivity of 45% and positive predictive value of 81% to predict macrosomia. AC >=35 cm have a negative predictive value of 99% and AC >=37 cm have a positive predictive value of 91% to predict an EFW of 4,000 gm. Soft-tissue measurements are used to evaluate the increase of fetal fat body mass. Cheek to cheek diameter, upper arm subcutaneous tissue, shoulder subcutaneous tissue can be used. Three-dimensional ultrasonography may offer volume assess of the thigh or upper arm.

[Monochorionic, monoamniotic twin pregnancies. Diagnostic problems. Outcome risk factors]. / Grossesses gémellaires monochoriales monoamniotiques. Problèmes diagnostiques. Risques évolutifs.

A monochorial monoamniotic twin pregnancy was conducted to term with the delivery of two live infants. The diagnostic problems are due to the rarity of this type of twin pregnancy. The main complications are recalled, essentially related to funicular and dystocic problems at delivery. Such pregnancies require careful management. A caesarean section should always be entertained.

[Short-term outcome of infants from triplet pregnancies. A series of 45 pregnancies]. / Devenir à court terme des enfants issus de grossesses triples. A propos d'une série de 45 grossesses.

OBJECTIVE: To evaluate outcome of triplets pregnancies. METHODS: A retrospective study about children of 45 triplet pregnancies which occurred spontaneously or after assisted reproductive technologies. All were managed by the same obstetrical and pediatric team. RESULTS: Mean birth weight was 1800 g and 26% of children were very low birth weights (< 1500 g). There was no difference in the mean Apgar score of pH between first, second and third infant. Neonatal and perinatal mortality rate were respectively 60 and 75%. Incidence of respiratory distress syndrome was 29%, hyaline membrane disease 11%, intraventricular hemorrhage (grade 4) 1.3%, necrotizing enterocolitis 10.5% and bronchopulmonary dysplasia 4%. Only 10% of the infants were not hospitalized and were kept by their mother. 38% of the newborns had to be hospitalized in a Neonatal Intensive Care Unit, with a mean stay of 6 days. At birth, 34% of the babies required intubation for artificial ventilation. CONCLUSIONS: The main problem of triplet pregnancies is high prematurity.

[Idiopathic thrombopenic purpura and pregnancy]. / Purpura thrombopénique idiopathique et grossesse.

The association of IPT (idiopathic thrombocytopenic purpura) and pregnancy happens rarely, but when it does it gives rise to two problems, the maternal and the neonatal. On the maternal level the risk is haemorrhage. Furthermore, the role of splenectomy in pregnancy still needs to be discussed; whereas all authors agree that treatment with corticoids and perhaps even with platelet transfusion may be necessary. As far as the newborn are concerned, it is common to find a low level of platelets which means that the newborn has particular risks of blood vessel rupture and intra-cranial haemorrhage (our observation). The attitude that the authors propose as far as the obstetric management of these cases is concerned is to carry out routine Caesarean section at term before labour starts. They analyse the other methods of dealing with these cases from the point of view of the maternal platelets and also from the fetal platelets estimated from scalp blood during labour.

[Hip algodystrophy and pregnancy]. / Algodystrophie de hanche et grossesse.

We report two cases of algodystrophy of the hip in pregnancy. The principle characteristics of the condition are: the occurrence of the symptoms in the second or third trimester of the pregnancy; and these are more marked on the left than on the right hip and radiological decalcification. MRI is accurate, specific and non invasive and it has largely taken the place of scintigraphy and tomodensitometry in making the diagnosis and in the differential diagnosis of early aseptic necrosis of the femoral head. Recovery always occurs in less than a year without sequelae. The physiopathogenic mechanism still is to be discussed but it does seem that the mechanical factors play a very important role.

[Obstetrical management of triplets. A series of forty five cases]. / Prise en charge obstétricale des grossesses triples. A propos d'une série de 45 cas.

OBJECTIVE: To evaluate management of triplet pregnancies. METHODS: A retrospective study of 45 triplet pregnancies which occurred spontaneously or after assisted reproductive technologies. All were managed by the same obstetrical and pediatric team. Obstetrical data were collected. RESULTS: Major etiologies were fertility drugs and in vitro methods (66%). Mean maternal age as 30 years, higher with assisted reproductive technologies (p < 0.05). Risks of chorioamniotitis, preeclampsia and anemia were respectively 4.4%, 13.3% and 70%. Triplets had a 100% prematurity rate and mean gestational age was 33.6 weeks; 22.2%, 51.1% and 64.4% delivered before respectively 32, 34 and 35 weeks of gestation. Triplet had a 91% cesarean section rate. CONCLUSION: Triplet pregnancies present a high risk of prematurity and infertility specialists have to be vigilant in the use of fertility drugs. Their management requires early reduced maternal physical activity.