Smoking and smoking cessation in pregnancy. Synthesis of a systematic review.

OBJECTIVES: To provide up-to-date evidence-based guidelines for the management of smoking cessation during pregnancy and the post-partum period. STUDY DESIGN: A systematic review of the international literature was undertaken between January 2003 and April 2019. MEDLINE, EMBASE databases and the Cochrane library were searched for a range of predefined key words. All relevant reports in English and French were classified according to their level of evidence ranging from 1(highest) to 4(lowest). The strength of each recommendation was classified according to the Haute Autorité de Santé (French National Authority for Health) ranging from A (highest) to C (lowest). RESULTS: "Counselling", including all types of non-pharmacological interventions, has a moderate benefit on smoking cessation, birth weight and prematurity. The systematic use of measuring expired air CO concentration does not influence smoking abstinence, however, it may be useful in assessing smoked tobacco exposure prior to and after quitting. The use of self-help therapies and health education are recommended in helping pregnant smokers quit and should be advised by healthcare professionals. Nicotine replacement therapies (NRT) may be prescribed to pregnant women who have failed to stop smoking after trying non-pharmacological interventions. Different modes of delivery and dosages can be used in optimizing their efficacy. Smoking in the postpartum period is essential to consider. The same treatment options as during pregnancy can be used. CONCLUSION: Smoking during pregnancy concerns more than a hundred thousand women each year in France resulting in a major public health burden. Healthcare professionals should be mobilised to employ a range of methods to reduce or even eradicate it.

[CNGOF-SFT Expert Report and Guidelines for Smoking Management during Pregnancy-Short Text]. / Rapport d'experts et recommandations CNGOF-SFT sur la prise en charge du tabagisme en cours de grossesse­texte court.

OBJECTIVES: To provide up-to-date evidence-based guidelines for the management of smoking cessation during pregnancy. METHODS: Systematic review of the international literature. We identified papers published between January 2003 and April 2019 in Cochrane PubMed, and Embase databases with predefined keywords. All reports published in French and English relevant to the areas of focus were included and classified according the level of evidence ranging from 1 (highest) to 4 (lowest). The strength of the recommendations was classified according to the Haute Autorité de santé, France (ranging from A, highest to C, lowest). RESULTS: "Counseling", involving globally all kind of non-pharmacological interventions, has a modest benefit on smoking cessation, birth weight and prematurity. Moderate physical activity did not show a significant effect on smoking cessation. The systematic use of feedback by measuring the expired air carbon monoxide concentration do not influence smoking abstinence but it may be used in establishing a therapeutic alliance. The use of self-help interventions and health education are recommended in helping pregnant smokers quit. The prescription of nicotine replacement therapies (NRT) may be offered to any pregnant woman who has failed stopping smoking without medication This prescription can be initiated by the health care professional taking care of the pregnant woman in early pregnancy. There is no scientific evidence to propose the electronic cigarette for smoking cessation to pregnant smokers; it is recommended to provide the same advice and to use methods that have already been evaluated. The use of waterpipe (shisha/narghile) during pregnancy is associated with decreased fetal growth. It is recommended not to use waterpipe during pregnancy. Breastfeeding is possible in smokers, but less often initiated by them. Although its benefit for the child's development is not demonstrated to date, breastfeeding allows the mother to reduce or stop smoking. The risk of postpartum relapse is high (up to 82% at 1 year). The main factors associated with postpartum abstinence are breastfeeding, not having a smoker at home, and having no symptoms of postpartum depression. CONCLUSIONS: Smoking during pregnancy concerns more than hundred thousand women and their children per year in France. It is a major public health burden. Health care professionals should be mobilized for reducing or even eradicating it.

[Operative risk related to tobacco in gynecology]. / Risque opératoire lié au tabac en gynécologie.

If tobacco has been recognized for many years as a major risk factor for cardiovascular, lung diseases and cancer in the general population, women are insufficiently aware of the consequences and the specific gynecological operative risks related to this intoxication. Thus, a regular tobacco consumption increases the risk for many gynecological conditions may require surgical treatment with in addition a significant negative impact on the healing process and the risk of postoperative complications. The operative risk must be explained by surgeons in daily practice gynecological, pelvic surgery or breast screening. The issue of smoking cessation should precede surgery has been established by a consensus conference of experts on perioperative smoking held in 2005. The implementation of these recommendations during the preoperative period requires improvement of staff training and better practices to allow smoking cessation effective and sustainable. It is lawful in this context to delay scheduled surgery of 6 to 8 weeks to allow an optimal smoking cessation and to continue smoking cessation for the time necessary for healing to reduce the excess operative risk associated with smoking.

Repellent effectiveness of seven plant essential oils, sunflower oil and natural insecticides against horn flies on pastured dairy cows and heifers.

Plant essential oils (basil, geranium, balsam fir, lavender, lemongrass, peppermint, pine and tea tree), mixed with either sunflower oil or ethyl alcohol, were applied at 5% concentrations to the sides of Holstein cattle. Pastured cattle treated with essential oils diluted in sunflower oil had less flies than the untreated control for a 24-h period. However, the essential oil treatments were not significantly different than the carrier oil alone. Barn-held heifers treated with essential oils and sunflower oil alone had significantly less flies than the untreated control for up to 8 h after treatment. Basil, geranium, lavender, lemongrass and peppermint repelled more flies than sunflower oil alone for a period ranging from 1.5 to 4 h after treatments applied to heifers. All essential oils repelled > 75% of the flies on the treated area for 6 and 8 h on pastured cows and indoor heifers, respectively. Geranium, lemongrass and peppermint stayed effective for a longer duration. Essential oils mixed with ethyl alcohol demonstrated less repellence than when mixed with the carrier oil. Safer's soap, natural pyrethrins without piperonyl butoxide and ethyl alcohol alone were not efficient at repelling flies. Essential oils could be formulated for use as fly repellents in livestock production.

[Screening and diagnosis of small for gestational age fetuses]. / Modalités de dépistage et de diagnostic du fœtus petit pour l'âge gestationnel.

OBJECTIVE: Define the mode of screening and diagnosis of fetal small for gestational age (SGA). METHODS: Bibliographic research by consulting Pubmed database and guidelines of the international professional societies. Keywords used: Intra uterine growth retardation or restriction, small for gestational age, curve, chart, fetal biometry, screening, velocity, fundal height measurement. RESULTS: The performance of ultrasound to detect SGA is low. The mode of screening and diagnosis of SGA must be well defined to be consensual. The fundal height measurement keeps its place in the screening from 22SA (grade C). The criteria for measuring ultrasound parameters defined by the comité technique d'échographie are recommended (professional agreement). They allow the calculation of the estimated fetal weight (EFW). That must be transferred to the reference curve adopted (professional agreement). The introduction of audit on techniques for measuring ultrasound parameters should be encouraged (grade B). CONCLUSION: Fetal biometry must be interpreted according to the clinical context and ultrasound including Doppler (grade C). To improve the performance of ultrasound, there is no need to another ultrasound examination in late pregnancy (grade A) except after a clinical suspicion (grade C). The minimum interval between two biometric tests is 3 weeks (grade B). This interval may be lower if the EFW is important in the decision of any fetal extraction (professional consensus).

Foetal serum but not urinary ß2-microglobulin correlates with histological injury to the kidney.

In a context of foetal obstructive uropathies, biochemical markers can be helpful to assess the renal function, but most studies to date have focused on their correlation with ultrasound findings and neonatal outcome. Our aim was to evaluate foetal ß2-microglobulin as an index of histological injury to the kidney. ß2-microglobulin was measured in serum and/or urine from 27 foetuses with bilateral obstructive uropathy, and compared to the findings of kidney examination following the termination of pregnancy. In serum, increased ß2-microglobulin levels correlated to a decreased number of glomeruli, a reduction in the blastema and the presence of primitive ducts reflecting renal hypoplasia and dysplasia. However, elevated ß2-microglobulin levels in the urine correlated only to a decreased number of glomeruli.

Fetal tumors of the choroid plexus: is differential diagnosis between papilloma and carcinoma possible?

Fetal choroid plexus tumors are uncommon. The prognosis is widely variable and depends on the histological findings: papilloma or carcinoma. We report a case of prenatal diagnosis of choroid plexus mass detected by ultrasound at 33 weeks of gestation. Prenatal (T1, T2, T2* and diffusion weighted sequences) magnetic resonance imaging (MRI) was used to rule out a hematoma. Follow-up examination by ultrasound and MRI revealed a significant increase in the volume of the mass, suggesting a diagnosis of malignant tumor. A healthy neonate was delivered by Cesarean section at 38 weeks of gestation. Full surgical excision of the tumor was performed at 20 days after delivery and histological analysis revealed a papilloma.

First-trimester ultrasound diagnosis of skeletal dysplasia associated with increased nuchal translucency thickness.

A series of five cases of skeletal dysplasia is reported in which the diagnosis was reached at the 11-14-week routine ultrasound examination in our referral center. All five cases had increased nuchal translucency thickness (NT) associated with bone abnormalities. We review the current literature on skeletal dysplasia in the first trimester of pregnancy associated with increased NT.

Prenatal demonstration of afferent vessels and progressive thrombosis in a torcular malformation.

OBJECTIVES: To elucidate a part of the prenatal natural history of dural sinus malformation of the posterior fossa. METHODS: Ultrasound and magnetic resonance imaging were performed from 31 to 32 weeks' gestation. RESULTS: We observed the progressive development of a thrombus that was visible as an expanding hyperechoic round area within a cystic mass of the posterior fossa. It was characterized, as expected for a vascular malformation, by the presence of blood flow into the aneurismal cavity. Color doppler identified superior sagittal and straight sinuses, and distinguished that their flow continued into the dilated torcular. Prenatal magnetic resonance imaging confirmed an arteriovenous malformation involving the dural sinus. CONCLUSION: The vascular malformation had a fixed volume and preceded the thrombosis, which formed within several days. The present case is the first report with all the prenatal sonographic features of this condition.

[Prevalence of smoking cessation during pregnancy according to trimester]. / Taux de sevrage tabagique chez la femme enceinte en fonction des trimestres.

OBJECTIVE: To investigate the smoking cessation period during pregnancy. PATIENTS AND METHODS: Questionnaire-based, descriptive study of 979 pregnant women in four regions of France. The variables analysed included the characteristics of the mother and neonate at delivery, the smoking habits of the mother before and during pregnancy, the perception of risk linked to smoking, and the reasons for giving up smoking. RESULTS: Eighteen percent of women smoked until delivery. Forty-five percent of women gave up smoking during pregnancy, usually in the first trimester. More precisely, about one woman who smoked out of 50 gives up in order to prepare pregnancy. The proportion of women who stop smoking in each of the three trimesters of pregnancy is 84,1, 8,8 and 7,1% respectively. DISCUSSION AND CONCLUSION: Most women appear to stop smoking before any intervention therapy is possible. The first contact with a midwife or an obstetrician takes place whereas smoking cessation is already successful.

[Obstetrical ultrasound screening and motivation to stop smoking]. / Echographies obstétricales et motivation à l'arrêt du tabac.

OBJECTIVES: To evaluate whether ultrasound screening during pregnancy increases the ability to stop or reduce smoking. MATERIALS AND METHODS: This multicenter questionnaire study was performed to describe smoking characteristics among pregnant women and evaluate the factors that influence the ability to reduce smoking during pregnancy. Questionnaire-based, descriptive study of 979 pregnant women in four regions of France. The variables analyzed included the characteristics of the mother and neonate at delivery, the smoking habits of the mother before and during pregnancy, and the reasons for giving up smoking. RESULTS: We report only results about ultrasound scan. One third of women, who smoked at the start of pregnancy, reported that ultrasound was a positive tool to enhance motivation to reduce smoking. CONCLUSION: Ultrasound screening may be a positive factor to reduce smoking. Our study focused on motivation could give a tool in this way. However most women who stop smoking during pregnancy do so in the first trimester (84%) mainly before the first ultrasound exam. Thus, the routine ultrasound scan itself does not seem to influence attitudes to stop smoking any further. But it may be included in comprehensive and individualised anti-smoking support.

[Effect of smoking on mode of delivery and per partum hypoxia and acidosis]. / Conséquences foetales du tabagisme sur les modes d'accouchement, l'hypoxie et l'acidose per-partum.

METHODS: We conducted a PubMed research using the following key words: fetal, smoking, distress, hypoxia, acidosis, heart rate, cesarean. RESULTS: The different combinations of key works allowed selection of 251 since 1967. Several article were addressed directly to the question raised; two for meconial fluid alone. One article detailed possible method biases. Several articles detailed the Apgar score in newborns of smoking mothers. Three calculated the risk of cesarean section in smokers. CONCLUSION: Data in the literature is not sufficient to argue in favor of an association between fetal asphyxia during labor and smoking. Only one study showed a higher rate of cesarean section in mothers smoking more than 10 cigarettes per day. Nevertheless, the Apgar score does not appear to be modified by moderate maternal smoking. Paradoxically, maternal smoking could have a protective effect on meconial aspiration and could have a moderately reducing effect on the rate of cesarean section during labor in patients smoking less than 10 cigarettes per day via lower fetal weight. These findings should be examined with caution because they still need to be confirmed and do not take into consideration other adverse effects of smoking on the fetus.

[Obstetrical perinatal care in case of maternal prenatal smoking]. / Conduite obstétricale périnatale en cas d'exposition maternelle anténatale au tabagisme.

Measurement of CO during the intrapartum period is a good way to help patients become aware of the importance of smoking cessation. The objective information can be continued in the post partum period. The effect is beneficial for the neonate and helps women stop smoking during subsequent pregnancies. To date, no study has been conducted during the intrapartum period useful for adapting our clinical practice in patients who smoke during pregnancy. Prospective studies, specifically designed to measure the impact of smoking on maternal and fetal complications during labor are essential.

[How can we help pregnant women stop smoking?]. / Peut-on aider les femmes enceintes qui fument?

Smoking is a behavior maintained and enhanced by nicotine-induced dependence. Despite awareness and knowledge of the associated health risks many smokers find it considerably difficult to quit. Nicotine withdrawal symptoms and undesirable effects such as depression and weight gain serve as justification for the numerous unsuccessful attempts in smoking cessation. Yet, we have now come to the end of empiricism. Treatments that have been shown to work exist and international evidence-based recommendations for cessation interventions have been established: brief advice, nicotine replacement therapy and behavioral and cognitive therapies. Measuring nicotine dependence using the Fagerström test helps to define the therapeutic strategy. Blood cotinine level can be measured during pregnancy. It is obvious that therapies can only work for smokers who are motivated to stop smoking. Before reaching the decision to quit, the smoker goes through a process during the course of which the role of information and advice from health professionals are paramount. When they became pregnant, young women are not necessary ready to quit. For many of them, pregnancy is sufficient motivation enabling them to stop smoking, but for thirty percent of them, probably the most dependent, it would be very difficult to stop without a specific program of help.

Congenital erythropoietic porphyria (Günther's disease): two cases with very early prenatal manifestation and cystic hygroma.

Congenital erythropoietic porphyria (CEP) or Günther's disease is the rarest form of the porphyrias. The disease is usually diagnosed at birth or during early infancy, but rarely in utero. We describe here the first two cases of very early prenatal expression of CEP with cystic hygroma diagnosed at 14 weeks in the first fetus and at 19 weeks in the second. Both fetuses presented with severe nonimmune hydrops fetalis as early as 19 and 22 weeks, associated with intrauterine growth retardation, hyperechogenic kidneys and bones. Amniotic fluid was dark brown and uro- and coproporphyrin I was dramatically increased. Molecular screening of the CEP gene detected heterozygous C73R mutation in both fetuses, the other parental mutation being as yet unknown.

Does high polyunsaturated free fatty acid level at the feto-maternal interface alter steroid hormone message during pregnancy?

Polyunsaturated fatty acids (PUFA) are important in pregnancy, fetal development and parturition. We measured free fatty acids (FFA), albumin and alpha-fetoprotein (AFP) in the maternal and fetal circulations of women undergoing elective Caesarean section at term. We also studied the impact of PUFAs on estrogen (ER) and progesterone receptors (PR) binding properties in vitro in the myometria of pregnant women and ex vivo in human myometrial cells in culture. FFA in intervillous blood (I) (feto-maternal interface) and maternal peripheral blood (M) were similar, while those in the umbilical vein (V) and arteries (A) were 2-4 fold lower (P<0.001). PUFA levels were low in M and 3 fold higher in I, A and V (P< 0.001); consequently C20:4 and C22:6 were most abundant in intervillous space. Albumin was uniformly distributed throughout the maternal-fetal unit, but there was a transplacental gradient in AFP. The AFP in the intervillous space had a special conformation (less immuno-reactive, more anionic), suggesting loading with PUFA. Physiological concentrations of C20:4 stimulated estradiol binding, but inhibited progestin binding. C20:4 inhibited progesterone binding by decreasing the number of binding sites, with no change in apparent affinity, in vitro in myometrial tissue and ex vivo in myometrial cells. Thus PUFA may modulate the steroid hormone message, so that the high C20:4 concentration at the maternal-fetal interface at term may help amplify the estrogen signal and inhibit the progesterone signal.

Effect of pregnancy on PDE4 cAMP-specific phosphodiesterase messenger ribonucleic acid expression in human myometrium.

In light of the important role of the second messengers cAMP and cGMP in the mechanism of relaxation in the human myometrium, specific regulation of the phosphodiesterase (PDE) enzymatic system responsible for cyclic nucleotide inactivation is essential. We previously identified in the human myometrium PDE4 cAMP-specific PDE as by far the most abundant isoform. Here we have studied the expression patterns of mRNAs for the four cloned human PDE4 genes in the myometria of pregnant and non-pregnant women. Concurrent expression of the PDE4A, 4B, 4C and 4D genes is demonstrated. We found that the PDE4D transcripts are the most prominently expressed. PDE4A and PDE4B mRNAs also are markedly abundant, whereas lower expression is observed for PDE4C mRNAs. Interestingly, we showed that transcripts of PDE4B2 are more abundant in the myometria of pregnant women than in non-pregnant women, whereas no difference between the two tissues was detected for PDE4A, 4C and 4D mRNAs. Cultured human myometrial cells, which present a high level of PDE4 activity and express the four PDE4 mRNA subtypes, provide us with an appropriate model to further evaluate whether the level of expression of the PDE 4B2 mRNA subtype is under hormonal regulation.