Edema associated with low plasma protein level and any gestational hypertension as warning signs of HELLP syndrome.

Purpose: Because preeclampsia is a multisystem disorder, its definition has recently been revised, including cases with evidence of renal, liver, neurological, or hematological dysfunction. However, the role of edema remains unclear. While the presence of mild edema is common in normal pregnancy, in severe preeclampsia protein transfer from the vascular into the interstitial compartment could lead to low serum protein level and favor the transport of fluid to the interstitial compartment.Materials and methods, Results: Over a 4-year period, 9749 women have given birth in our university maternity ward. In this period of time, 86 women developed severe preeclampsia. Among them, we retrospectively identified nine patients who first presented with mild de novo hypertension or preeclampsia, extensive edema or excessive gestational weight gain (GWG), and documented low serum protein levels; five patients also reported headache. Serum protein levels ranged from 51 to 56 g/l. We analyzed the progression of the disease in these women, and found that these patients developed criteria for complete or partial hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome in four and five cases, respectively. All patients were delivered quickly of healthy babies, and no other maternal adverse outcomes occurred.Discussion: As plasma proteins are the primary determinants of plasmatic colloid osmotic pressure (COP), headache in association with edema, low serum protein levels, and even mild hypertension, could reflect cerebral vasogenic edema with the same mechanism as for cerebral edema reported in posterior reversible encephalopathy syndrome and eclampsia. Thus, the sequential association of edema or excessive GWG with markedly low serum protein levels and mild gestational hypertension could signal the imminent development of severe preeclampsia and possibly HELLP syndrome. This sequence should be assessed in additional large-scale prospective studies.

Use of the EFI score in endometriosis-associated infertility: A cost-effectiveness study.

BACKGROUND: The management of endometriosis-related infertility is still under debate. The Endometriosis Fertility Index (EFI) score is performant to predict the occurrence of a spontaneous pregnancy following surgery, but was not evaluated in a cost-effectiveness perspective. Our objective was to quantify fertility outcomes, and costs of different care pathways for endometriosis-associated infertility after primary surgery, with a stratification on the EFI score. STUDY DESIGN: We conducted a cost-effectiveness analysis based on a decision-tree model in a Tertiary-care university hospital. Extracted form a prospectively maintained database, 608 patients with endometriosis-associated infertility, who underwent laparoscopic treatment with an evaluation of the EFI score, were discriminated between different strategies: natural conception, immediate IVF-ICSI, delayed IVF-ICSI. The pregnancy rate and the live birth rate were the effectiveness outcomes. We considered direct and indirect costs in each strategies. The analysis was stratified according to the EFI score. RESULTS: After surgery, 163 women with immediate IVF-ICSI (strategy I) were compared with 445 women who had natural conception attempts during a year (strategy II). After a year failure of natural conception attempts, 133 women continuing natural conception attempts (strategy III) were compared with 168 women who had delayed IVF-ICSI (strategy IV). The respective PR and LBR were 62.6 % and 52.1 % for strategy I, and 32.4 % and 23.8 % for strategy II. Compared to strategy II, strategy I was more costly and more effective (Incremental Cost Effectiveness Ratio (ICER): 31,469 €/pregnancy and 33,568 €/live birth)). No added benefit was observed for patients in strategy I with an EFI score [0-3] after two IVF-ICSI cycles. Strategy III was strongly dominant versus strategy IV for patients with an EFI score [9-10]. Compared to strategy III, strategy VI was more costly and more effective (ICER: 79,674 €/pregnancy, 53,188 €/pregnancy and 27,748 €/pregnancy respectively for patients with an EFI score [7-8], [4-6] and [0-3]). CONCLUSION: Immediate IVF-ICSI after surgery is effective but associated with substantial costs for the healthcare system. Taking into account healthcare costs, the EFI is a useful score for helping a couple decide between different care pathways -natural conception, immediate or delayed IVF-ICSI- after surgery for endometriosis-associated infertility.

Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies.

BACKGROUND: The debate surrounding the management of term breech presentation has excessively focused on the mode of delivery. Indeed, a steady decline in the rate of vaginal breech delivery has been observed over the last three decades, and the soundness of the vaginal route was seriously challenged at the beginning of the 2000s. However, associations between adverse perinatal outcomes and antenatal risk factors have been observed in foetuses that remain in the breech presentation in late gestation, confirming older data and raising the question of the role of these antenatal risk factors in adverse perinatal outcomes. Thus, aspects beyond the mode of delivery must be considered regarding the awareness and adequate management of such situations in term breech pregnancies. MAIN BODY: In the context of the most recent meta-analysis and with the publication of large-scale epidemiologic studies from medical birth registries in countries that have not abruptly altered their criteria for individual decision-making regarding the breech delivery mode, the currently available data provide essential clues to understanding the underlying maternal-foetal conditions beyond the delivery mode that play a role in perinatal outcomes, such as foetal growth restriction and gestational diabetes mellitus. In view of such data, an accurate evaluation of these underlying conditions is necessary in cases of persistent term breech presentation. Timely breech detection, estimated foetal weight/growth curves and foetal/maternal well-being should be considered along with these possible antenatal risk factors; a thorough analysis of foetal presentation and an evaluation of the possible benefit of external cephalic version and pelvic adequacy in each specific situation of persistent breech presentation should be performed. CONCLUSION: The adequate management of term breech pregnancies requires screening and the efficient identification of breech presentation at 36 weeks of gestation, followed by thorough evaluations of foetal weight, growth and mobility, while obstetric history, antenatal gestational disorders and pelvis size/conformation are considered. The management plan, including external cephalic version and follow-up based on the maternal/foetal condition and potentially associated disorders, should be organized on a case-by-case basis by a skilled team after the woman is informed and helped to make a reasoned decision regarding delivery route.

Term spontaneous trial of labor in nulliparous women of short stature: A hospitals-based cohort study.

OBJECTIVES: To study the mode of delivery in a well selected cohort of short nulliparous women. STUDY DESIGN: Hospitals-based cohort study between 2010-2018. The threshold (150 cm, i.e 2,3°p), for the short stature was chosen before the analysis by corresponding to - 2SD of the average population size distribution of all women who delivered over the same period: 2010-2018. Were included nulliparous women with a heigh ≤ 150 cm in term spontaneous labor with a single livung fetus in vertex presentation without malformation. Exclusion criteria were: multiparous, scarred uterus, twin pregnancy, induced labor, preterm delivery (< 37 W P), non-vertex pregnancy, medical termination of pregnancy, stillbirth, severe fetal malformations, pre-labor cesarean, and late dating ultrasound. The main outcome was the mode of delivery. Univariate and multivariate analysis adjusted on potential confounding variable were performed to investigate the risk of intrapartum CS. RESULTS: 178 nulliparous women were included. The mean height was 148 cm. The rate of spontaneous vaginal delivery, operative vaginal delivery a nd intrapartum CS were :35,4 %, 35,4 % and 29,2 % respectively. Intrapartum CS was performed during the first stage labor in 15 (28, 8 %) women and during the second stage in 37 (71, 2 %) women. An arrest of labor was significantly more frequent in the active labor than the early labor stage: 62,1 % vs. 33.3 % (p = 0, 02). In univarate analysis were associated with intrapartum CS : Gestational diabetes, birthweight> 3,5 kg, individual adjusted birthweight >90°p, occiput posterior, oxytocin use, cephalic circumference. After adjustment on birthplace and overweight (BMI over 25), only a birthweight > 3,5 kg remains associated with the risk of intrapartum CS (aOR4.3 ;95 %CI 1.96-10.2). CONCLUSION: An attempt of vaginal birth is a reasonable option for short stature women. Maternal height could be included in the selection criteria for planned birth center or home birth. The customized gestational-related optimal weigh could be useful to identify large of gestational age fetus.

Genital zoster in near term pregnancy: Case report and need of management guidelines.

Genital herpes simplex infection close to delivery may be transmitted to the newborn. Guidelines for genital herpes during pregnancy have been elaborated to reduce the risks of neonatal herpes. Genital herpes zoster due to reactivation of varicella zoster virus (VZV) from sacral ganglia is an under recognized cause of genital lesions. The risks of genital zoster near delivery for the newborn have not been evaluated. No guidelines have taken into account this rare viral infection during pregnancy. A pregnant woman at 38 weeks gestation presented herpes-like genital vesicular lesions in absence of herpes simplex virus (HSV) past history. Rapid HSV molecular testing was negative despite clinically suggestive lesions. A control multiplex PCR was performed, which evidenced VZV. The woman was treated with acyclovir until delivery. The newborn was healthy. VZV should be investigated in HSV- negative herpes-like genital lesions during pregnancy. Diagnosis of genital lesions requires virological confirmation to adapt obstetrical and neonatal management.