[Ultrasound of the fetal urinary system during the first trimester of pregnancy]. / Échographie de l'appareil urinaire fœtal au 1er trimestre de la grossesse.

The detection of abnormalities of the fetal urinary system in the first trimester of pregnancy is constantly improving, namely owing to the improved resolution of the image, the use of the endovaginal approach and thanks to sonographers' constant training. The pathological aspects, usually detected in the second trimester of pregnancy, can be suspected early in the first trimester and range from kidneys' cavity dilation to bilateral renal agenesis, polycystic kidney disease, multi-cystic dysplasia and bladder megavessia or bladder exstrophy. A poly-malformative syndrome is to be found out. The detection of an abnormality of the urinary tract requires a close ultrasound check. Very often, the pathological aspects tend to disappear spontaneously. In particular, the non-visualization of the bladder requires repeated examinations during the same session or even a little later in the pregnancy. We will carry out a review of the literature by pointing out the usual and unusual aspects of the fetal urinary system visible in the first trimester and we will as well propose an algorithm describing how to deal with abnormalities of the urinary tract that can be found out at first trimester ultrasound.

[Evaluation of controlled-release dinoprostone Propess for labor induction]. / Utilisation du dispositif vaginal Propess dans le déclenchement du travail: efficacité et innocuité

OBJECTIVE: To evaluate the efficacy of cervix ripening with vaginal controlled-release Propess. PATIENTS AND METHODS: A retrospective study of all women who underwent cervical ripening with Propess during the study period from 1(st) January 2002 to 31(st) December 2004 was carried out. A total of 130 patients who experienced Propess was compared with the next following patient who delivered spontaneously matched on gestational age. Modes of delivery, failure of labor, maternal morbidity were recorded. RESULTS: Indications for induction of labor were: post-term pregnancies in 18.5%, pre-eclampsia in 20.8%, oligohydroamnios in 18.5%, post-term pregnancy and oligohydramnios in 10.8%, intra-uterine fetal growth in 6.9%, premature rupture of membranes in 6.9%, diminution of fetal mobility in 6.1% and miscellaneous in 11.5%. Failure of cervical ripening was 21.2%. Patients in the Propess group had a 3.5 fold higher risk of Cesarean section [95% CI: 1.5-8.3; P < 0.04]. There was no case of maternal or fetal death. There was no difference in incidence of maternal complications, and post-partum haemorrhage. DISCUSSION AND CONCLUSION: Use of vaginal pessary Propess does not induce adverse maternal or fetal morbidity. However, it was associated with a higher incidence of Cesarean delivery.

[Delivery of a macrosomic infant: factors predictive of failed labor]. / Accouchement du foetus macrosome: facteurs prédictifs d'échec de l'épreuve du travail.

OBJECTIVE: To determine risk factors of failed labor in case of fetal macrosomia. MATERIALS AND METHODS: Medical charts of two hundred and forty six women who delivered macrosomic infants (>4,000g) between January 2004 and May 2005 were reviewed. Maternal and obstetrical data were analyzed by mode of delivery. Univariate and multivariate (logistic regression analysis) were performed to identify risk factors of failed labor. RESULTS: Rate of cesarean delivery was 18.3%. Indications for cesarean were: failure to progress in 55.6%, arrest in fetal descent in 22.2%, fetal distress in 6.7%, and other in 8.9%. There was a higher risk of failed labor in nulliparous women (p<0.001), in case of a symphysio-fundal measurements>34cm (p=0.004), in nulliparity associated with symphysio-fundal measurements>34cm (p<0.001), in case of previous cesarean delivery (p=0.004), in cases of maternal height<1.65m (p=0.02), and with ocytocin use (p=0.05). In multivariate analysis, nulliparity associated with symphysio-fundal measurements>34cm (OR=5.2; CI 1.5-18.4), previous cesarean section (OR=3.7; CI 1.1-12.4) and maternal height<1.65m (OR=2.6; CI 1.2-5.5) were independent factors of failed labor. CONCLUSION: Failure of labor in case of macrosomia can be predicted in the event of previous cesarean section, shorter maternal height, and association of nulliparity and symphysio-fundal measurements>34cm.

[Evaluation of adherence to French guidelines concerning the information of the women having a scarred uterus on their mode of delivery]. / Évaluation du suivi des recommandations concernant l'information des patientes ayant un utérus cicatriciel sur leur mode d'accouchement.

OBJECTIVE: To evaluate adherence of obstetricians from our maternity to French practice guidelines concerning information to give to pregnant patients with a history of scarred uterus. MATERIALS AND METHODS: Observational retrospective study performed on medical files from June to August 2014 and concerning women with a scarred uterus that gave live-birth after 37weeks of gestation. Information of patients had to concern the risks of a history of caesarean, the benefits and risks of the various delivery modes. RESULTS: On 758 deliveries, 77 cases were studied: 48 patients were followed up from the beginning of pregnancy, 23 from the 2nd trimester and 6 were not followed. Among patients followed from the beginning, no data was written on medical file concerning information that should to be given in immediate post-partum, in preconception counseling, and at the beginning of pregnancy about the risks of scarred uterus and the mode of delivery. In the 8th month, information about benefits and risks of the planned delivery mode was noticed in 45% of files. CONCLUSION: The information that need in theory to be given to the patients with scarred uterus appeared little or insufficiently noticed on medical files; which can be due either to an inaccurate information, or to a lack of transcription of the information nevertheless given. A check-list in obstetrical file would help to systematize the information to provide in scarred uterus patients.

[Methods of induction of labor in termination of pregnancy after 22weeks: About 3procedures]. / Modalités d'induction du travail des interruptions médicales de grossesse après 22SA : à propos de 3protocoles.

OBJECTIVES: To propose a protocol for induction of labor to terminate pregnancy after 22weeks of amenorrhea allowing to decrease the duration of labor and of hospitalization but also, allowing to reduce the number of emergency pretreatment-induced fetal death, to improve the experience of the patients and to limit the cost. METHODS: We realized a retrospective single-center study including 269patients and comparing three protocols, with and without laminaria and with various intervals mifepristone-misoprostol (14 and 38hours). The outcome measures were the misoprostol-delivery interval, the delivery time and the number of emergency pretreatment-induced fetal death. RESULTS: We showed that the misoprostol-delivery interval and the delivery time were comparable for the three periods of our study, even after decrease of 24hours of the mifepristone-misoprostol interval and in the absence of laminaria. The misoprostol-delivery interval was between 7h30 and 8h35 between protocols (P=0.055). The delivery time was between 5:18pm and 6:48pm between protocols (P=0.252). The early administration of misoprostol allowed the patients to give birth earlier (P=0.001). Finally, we showed that the increase of the size and the number of laminarias were risk factors of emergency pretreatment-induced fetal death (respectively P=0.013 and P=0.002). CONCLUSION: The absence of laminaria and the reduction of the interval mifepristone-misoprostol of 24hours do not change the time to delivery and allow to reduce the duration of hospitalization, the number of emergency pretreatment-induced fetal death and the cost of the TOP.

Prenatal diagnosis of bowel malposition using T2-weighted fetal MRI sequences.

OBJECTIVE: The goal of this study was to investigate the capability of T2-weighted magnetic resonance imaging (MRI) in revealing fetal bowel malposition. MATERIALS AND METHODS: All fetal MRI examinations (excluding central nervous system MRI examinations) performed in our department from January 2005 to January 2014 were retrospectively studied by 2 independent observers for situs, stomach and jejunum location on T2-weighted images. Patients data were also reviewed for results of ultrasound examinations, MRI indication, and gestational age. Abnormally positioned jejunums were classified into 3 groups: intrathoracic (A), extra-fetal (B) and abnormal intra-fetal (C). Prenatal data were compared to postnatal imaging, surgery or autopsy findings that served as standard of reference. RESULTS: A total of 709 fetal MRI examinations were analyzed. In 64 fetus (9%), the jejunum was not present in the left subgastric area on T2-weighted MR images. In these 64 fetuses, proximal jejunum was intrathoracic (41/64, 64%, group A), extra-fetal (11/64, 17%, group B), or intra-abdominal but abnormally positioned (12/64, 19%, group C). Interobserver agreement was 100%. All diagnoses for fetuses in groups A and B (52 cases) were confirmed postnatally (41 cases) or at autopsy (11 cases). In group C, bowel malposition was suspected after ultrasound in only 2/12 fetuses (16.6%); it was confirmed postnatally in 1 fetus but not confirmed in the remaining one. In the 10 remaining fetuses (83%), malposition was confirmed postnatally although not initially suspected. CONCLUSION: T2-weighted fetal MR images are useful for the prenatal diagnosis of bowel malposition, even when they are unsuspected on ultrasound examination.

Diagnosis and management of adenocarcinoma of the ampulla of Vater during pregnancy.

BACKGROUND: Cancer of the biliary tract has a poor prognosis and its association with pregnancy is uncommon. Early diagnosis allowing curative surgical resection offers the only hope of long-term survival. CASE: This report describes the case of a young 26-week-pregnant woman admitted for cholestatis documented by clinical and laboratory examination. Ultrasonography (US) and magnetic resonance cholangiopancreatography (MRCP) were indicative of common bile tract obstruction. Caesarian section was performed at 32 weeks of pregnancy and the tumor was promptly biopsied. Histology demonstrated carcinoma of the ampulla of Vater. The patient underwent a Whipple procedure. Both mother and baby survived. CONCLUSION: Pregnant patients with digestive cancer require careful management. Acute non-invasive assessment and radical surgery improve outcome for both the mother and fetus.

[Chorionic villus needle sampling by the transabdominal route or by placental centesis. A series of 930 cases]. / Les prélèvements de villosités choriales à l'aiguille par voie transabdominale ou placentocentèses. Une série de 930 cas.

The authors report on a series of 930 chorion villus sampling diagnoses made with a needle by the transabdominal route, from January 1991 to October 1992 at the Prenatal Diagnosis Center in Marseille. Indications for prenatal diagnosis were: raised maternal age in 75% of cases (N:698); ultrasound findings in 11% (N:106), chromosome abnormalities in the family in 6% cases (N:53), raised human chorionic gonadotrophin in 4% cases (N:38), parental rearrangement in 2% cases (N:20), and sex linked disease in 1% (N:15). The success rate was 97% with 29 failures; the number of needle insertions was one in 97% cases and two in 3% cases. The average gestational age at sampling was related to the indications; 16 weeks of amenorrhoea for raised maternal age, and 22 weeks of amenorrhoea for ultrasound findings. Thirty one abnormalities were observed, four balanced translocations, and seven placental mosaicisms. Forty eight pregnancies terminated in abortion. The rate of fetal loss was 3.5% (7 cases) for the 200 first cases and 1% (8 cases) for the 730 following cases. Choriocentesis through the transabdominal route provides a diagnosis within a few days and the rate of fetal loss is close to that of amniocentesis. These arguments are in favour of an extension of this method of sampling.

PIP: Between January 1, 1991, and September 30, 1992, at the Prenatal Diagnostic Center in Marseille, France, physicians used a needle via the transabdominal route to take chorionic villus samples (CVS) from 930 pregnant women. The indications for CVS were advanced maternal age (75%), ultrasound findings (11%), chromosome abnormalities in the family (6%), high human chorionic gonadotropin levels (4%), chromosomal rearrangement in parent (s) (2%), and condition linked to chromosome X (1%). Only 1 needle puncture was needed in 97% of cases. CVS was successful in 97% of women. Heat denaturation did not allow a satisfactory structural analysis of chromosomes in 29 cases. The average gestational age at CVS was 16 weeks for advanced maternal age and 22 weeks for ultrasound findings. Cytogenetic tests were normal in 95.5% of cases. Chromosomal abnormalities were present in 31 cases, balanced translocations in 4 cases, and placental mosaicisms in 7 cases. 48 women chose to undergo medical abortion for chromosome abnormality in 31 cases and ultrasound-identified malformations in 17 cases. The fetal loss rate was 3.5% for the first 200 CVS cases compared to 1% for the next 730 cases. The fetal loss rate for CVS performed by trained and experienced professionals is similar to that for amniocentesis (0.4-1%). CVS via transabdominal route allowed a diagnosis within 24-28 hours for a chromosomal abnormality of numbers and several days for a structural abnormality. These findings support greater use of this method of CVS.

[Pronostic risk assessment of delivery, in patients admitted for threatened preterm birth, in a tertiary care maternity center]. / Étude pronostique du risque d'accouchement, des patientes hospitalisées pour menace d'accouchement prématuré, dans une maternité de niveau III.

OBJECTIVES: To assess preterm birth rate, in patients admitted for threatened preterm birth (TPB) in a tertiary care maternity center and evaluate our diagnostic and therapeutic tools. MATERIALS AND METHODS: A retrospective cohort study, in a tertiary care maternity center (Marseille, France), reviewed all admissions for TPB from January 1 to December 31, 2009. RESULTS: We recorded 224 admissions for TPB (181 single pregnancies and 43 twin pregnancies), 43.8% of TPB admissions were from materno-fetal transfer. Preterm birth rate was 44.9% (n=89), 39% (n=66) for single pregnancy and 76.6% (n=23) for twins. The 15 mm threshold for transvaginal sonography cervical length (CL) was the most relevant to predict the risk of preterm delivery, 77.3% (85/110) of patients with CL>15 mm having full term delivery. CONCLUSION: For single pregnancy, most of the patients with cervical length>15 mm have full term delivery. It seems important to us to develop the use of more efficient predictive markers of risk-premature labor in order to improve the diagnosis and management of TPB.

[Cervical ripening at term with repeated administration of dinoprostone vaginal pessary]. / Maturation cervicale à terme par utilisation répétée du dispositif intravaginal de dinoprostone.

OBJECTIVES: To evaluate efficacy and safety of cervical ripening with repeated administration of dinoprostone slow release vaginal pessary (Propess®) in current practice. PATIENTS AND METHODS: An observational study of 111 women who underwent cervical ripening with two Propess® during the study period from 1st July 2007 to 31st October 2011. Modes of delivery, success of cervical ripening, failure of labor induction, maternal and neonatal morbidity were reported. RESULTS: The nulliparous rate was 75,7%. The main indications for induction of labor were post-term pregnancy in 34,3% (38/111) and premature rupture of membranes in 25,2% (28/111). The rate of vaginal delivery was 53,1% (59/111). Cesarean sections were performed for failure of labor induction in 27/52 (51,9%) and an abnormal fetal heart rate in 17/52 (32.7%). Indication for induction of labor, nulliparous patients (44 [84.6%] versus 40 [67.8%]; P=0.04), initial Bishop score (2.2±1.2 versus 2.9±1.2; P=0.04) before the cervical ripening and Bishop score before administration of second Propess® (3.3±1.4 versus 4.0±1.2; P=0.05) were significant risk factors of cesarean delivery. DISCUSSION AND CONCLUSION: In more than half of the cases, the cervical ripening by two Propess® is efficient and allows a vaginal delivery. This practice does not appear to increase the maternal or neonatal morbidity.

Development and internal validation of a nomogram to predict macrosomia.

OBJECTIVE: To develop a nomogram to predict macrosomia with a combination of clinical and ultrasound variables. METHODS: Data from 194 women who underwent sonographic fetal weight estimation were used to develop and calibrate a nomogram to predict fetal macrosomia. The nomogram was subjected to 200 bootstrap resamples for internal validation and to reduce overfit bias. An Internet-based tool was developed to facilitate use of the nomogram. RESULTS: The macrosomia prediction nomogram, based on parity, ethnicity, body mass index and fetal weight estimated macrosomia, had good discrimination and calibration before and after bootstrapping (area under curve (AUC), 0.860 and 0.850, respectively). The predictive accuracy of our nomogram was significantly better than was sonographically estimated fetal weight using Hadlock's formula (AUC, 0.740; P<0.001). We have provided a web-based interface to predict the individual probability of macrosomia. CONCLUSION: We have developed a nomogram to predict the individual probability of macrosomia based on clinical and ultrasound findings. Our web-based interface should help to guide patients and physicians in decision-making.

[Home delivery]. / L'accouchement à domicile.

Home delivery, although unconventional, has not totally disappeared. It sometimes results from the desire to "demedicalise" an event deemed natural and is sometimes the consequence of government policy and hence approved by medical authorities. This is the unique situation of Holland, where a highly efficient home delivery system has been created, with the possibility of transfer of the mother at any time to rapidly available emergency medical teams. In fact the large majority of home deliveries are accidental, unprepared and take place in the absence of any medical or paramedical assistance. All available studies show that perinatal and maternal morbidity associated with these accidental deliveries is greater than that of hospital deliveries, and this despite the setting up of emergency services responding as soon as a distress call is received. Home delivery should remain the exception at present since it is unable to guarantee a birth as undangerous as possible.