Pre-pregnancy body mass index and weight gain during pregnancy: relations with gestational diabetes and hypertension, and birth outcomes.

To study the relationship between pre-pregnancy body mass index (BMI) and weight gain during pregnancy with pregnancy and birth outcomes, with a focus on gestational diabetes and hypertension and their role in the association with fetal growth. We studied 1,884 mothers and offspring from the Eden mother-child cohort. Weight before pregnancy (W1) and weight after delivery (W2) were collected and we calculated BMI and net gestational weight gain (netGWG = (W2 - W1)/(weeks of gestation)). Gestational diabetes, hypertension gestational age and birth weight were collected. We used multivariate linear or logistic models to study the association between BMI, netGWG and pregnancy and birth outcomes, adjusting for center, maternal age and height, parity and average number of cigarettes smoked per day during pregnancy. High BMI was more strongly related to the risk of giving birth to a large-for-gestational-age (LGA) baby than high netGWG (odds ratio OR [95% CI] of 3.23 [1.86-5.60] and 1.61 [0.91-2.85], respectively). However, after excluding mothers with gestational diabetes or hypertension the ORs for LGA, respectively weakened (OR 2.57 [1.29-5.13]) for obese women and strengthened for high netGWG (OR 2.08 [1.14-3.80]). Low in comparison to normal netGWG had an OR of 2.18 [1.20-3.99] for pre-term birth, which became stronger after accounting for blood pressure and glucose disorders (OR 2.70 [1.37-5.34]). Higher net gestational weight gain was significantly associated with an increased risk of LGA only after accounting for blood pressure and glucose disorders. High gestational weight gain should not be neglected in regard to risk of LGA in women without apparent risk factors.

Influence of fetal and parental factors on intrauterine growth measurements: results of the EDEN mother-child cohort.

OBJECTIVE: In small-for-gestational-age neonates, parental and fetal characteristics can be used to distinguish between constitutionally small size and growth restriction, which is associated with a higher risk of morbidity and mortality. The aim of this study was to quantify relationships of parental and fetal characteristics with fetal ultrasound measurements. METHODS: The EDEN mother-child cohort included 2002 pregnant women with singleton pregnancies attending one of two university hospitals. Data from two routine ultrasound examinations for fetal biometry were recorded, at 20-25 and 30-35 weeks of gestation. Biparietal diameter (BPD), head circumference (HC), femur length (FL), abdominal circumference (AC) and estimated fetal weight (EFW) were studied as a function of prepregnancy maternal body mass index (BMI), maternal height, paternal height, fetal sex and gestational age. RESULTS: Data were obtained at the first scan from 1833 women and at the second scan from 1752 women. Parental anthropometric characteristics were significantly associated with ultrasound measurements at both scans. Maternal BMI was more strongly associated with AC and EFW, whereas both maternal and paternal height were more strongly associated with FL. An association was also found between fetal sex and all ultrasound measurements other than FL. CONCLUSION: Maternal and paternal anthropometric characteristics are significantly associated with ultrasound measurements in mid to late pregnancy. These relationships provide support for the use of these characteristics in ultrasound fetal size reference charts.

A retrospective study by oligonucleotide array-CGH analysis in 50 fetuses with multiple malformations.

OBJECTIVE: To retrospectively define the frequency and the nature of submicroscopic chromosomal imbalances among fetuses with multiple congenital anomalies (MCA). METHODS: We used oligonucleotide arrays to perform comparative genomic hybridization after termination of pregnancy in 50 polymalformated fetuses with a normal karyotype. These fetuses presented with at least three significant malformations (42 cases) or a severe brain anomaly (eight cases). RESULTS: We identified a deleterious copy number variation (CNV) in five fetuses (10%). De novo genomic imbalances identified in this study consisted of a 6qter deletion in a fetus with brain and renal malformations, a mosaicism for a 8p tetrasomy in a fetus with agenesis of corpus callosum, growth retardation, mild facial dysmorphic features, and vertebral anomalies, a 17p13.3 deletion in a fetus with a complex brain malformation, and a partial 11p trisomy in a fetus with severe growth retardation and oligoamnios. In one case, we identified a partial 17q trisomy resulting from malsegregation of a cryptic-balanced translocation. CONCLUSIONS: This study shows that array comparative genomic hybridization (aCGH) is particularly effective for identifying the molecular basis of the disease phenotype in fetuses with multiple anomalies. Our study should help to define clinical relevant regions that would need to be included in targeted arrays designed for prenatal testing.

[Difficulties of interpretation in toxoplasma serology in a pregnant woman in the context of a maternofetal alloimmunization against HPA-1a platelet antigen]. / A propos d'un cas de sérologie toxoplasmique chez une patiente enceinte dans un contexte d'allo-immunisation foetomaternelle anti-HPA-1a.

Serological status in case of Toxoplasma gondii infection needs to be established either before or at the beginning of a pregnancy. However, clinical biologists are often facing conflicting serological results that are difficult to interpret: we report here the case of a woman in her 30th week of pregnancy. Both her IgM and IgG were negative at the 14th week of pregnancy; but suddenly, starting from the 20th week, her IgG became positive while her IgM remained negative. We remind here of the most frequent hypothesis that can explain a sudden and isolated increase of anti-T. gondii IgG: Is it a technical problem (specificity)? Is it a drug interference? Eventually, we found that the patient was receiving, since the 16th week of pregnancy, every week an intravenous perfusion of polyvalent immunoglobulins. Since we didn't know if the IgG present in this perfusion can protect the patient against toxoplasmosis, we decided to consider this women as non immune.

[Pelvic inflammatory diseases]. / Physiopathologie, diagnostic et prise en charge des infections génitales hautes.

Pelvic inflammatory diseases (PID) include salpingitis and endometritis. They usually result from the infection of upper genital tract by pathogens ascending from the cervix or the vagina. Since the clinical signs of uncomplicated forms are frequently mild or misleading, diagnosis require other exams such as microbiology (samples from the cervix and, if applicable, from the pelvis) and laparoscopy. Acute complications (pelvic abscesses, peritonitis) can occur, that call for both surgical drainage and antibiotics. Pelvic sequelae with permanent tubal alterations due to immuno-allergic reactions can also happen, that lead to chronic pelvic pain and infertility. Treatment consists in broad-spectrum antibiotics by oral route, combined with non steroid anti-inflammatory drugs. Atraumatic laparoscopic procedure can also be performed.

Should parity be included in customised fetal weight standards for identifying small-for-gestational-age babies? Results from a French multicentre study.

OBJECTIVE: Parity is one of several parameters used to customise fetal growth norms. However, it is uncertain whether the lower birthweight of babies born to primiparous women reflects physiological or pathological variation. Our aim was to assess the impact of adjusting for parity in identification of small-for-gestational-age (SGA) births. DESIGN: Comparison of two customised definitions of SGA with and without parity. SETTING: Routinely collected data in five tertiary maternity hospitals in France. POPULATION: A total of 51 126 singleton births without malformations from 1997 to 2002. METHODS: Characteristics of mothers and babies and adverse pregnancy outcomes for SGA and non-SGA births were compared using customised definitions with and without parity. MAIN OUTCOME MEASURES: Neonatal morbidity and mortality. RESULTS: SGA births among primiparas increased from 14.9 to 18.0% when parity was excluded. Overall rates of SGA rose from 14.4 to 15.0%. Newly defined cases of SGA were babies of primiparas. They had higher rates of admission to a neonatal unit and caesarean section than babies reclassified as non-SGA. Perinatal mortality was 9.1 per thousand (parity included) and 9.7 per thousand (parity excluded) and did not differ significantly from babies classified as non-SGA by both standards (5.4 per thousand). CONCLUSIONS: Adjustment for parity markedly decreased the proportion of primiparas diagnosed with SGA babies but did not appear to improve the identification of high-risk babies. Removing parity would simplify the customised definition of SGA and would eliminate the need for the assumption that lower birthweight for primiparous women is normal.

[Fetal pulse oxymetry]. / Oxymétrie de pouls foetal.

Labor is monitored to avoid per partum asphyxia and its consequences. Cardiotocography enables asphyxia detection but carries unuseful cesarean sections. When cardiotocography is not reassuring, fetal pulse oxymetry makes it possible to reduce cesarean section rate for non-reassuring fetal status. Nevertheless, there is an increased number of cesarean sections for dystocia that could be due to the presence of the oxygen sensor itself. A global reduction is mainly observed when oxymetry is associated with fetal blood sampling for pH measurement. In this case, oxymetry also makes it possible to reduce the number of necessary samplings.

[Is primiparity, the only risk factor for type 3 and 4 perineal injury, during delivery?]. / La primiparité est-elle le seul facteur de risque des lésions du sphincter anal en cours d'accouchement?

OBJECTIVE: Primiparity has been identified as the main risk factor of type 3 and 4 perineal injuries The purpose of our study, according to a population-based observational study, was to identify other clinical risk factors for lesions during vaginal delivery. PATIENTS AND METHODS: Two groups have been compared. Group A or study group (n=63) was defined as parturients with three or four-degree perineal tears. Group B or control group (n=67) included women who delivered vaginally without any perineal lesion during the same period. Characteristics of the population were compared: maternal age, race, maternal weight, BMI (Body Mass Index), parity, mode of anaesthesia, gestational age, post maturity, length of labor, fetal weight, mode of delivery (assisted or not). Specific characteristics were also compared, obesity, shoulder dystocia, type of presentation, episiotomy and dose of ocytocin. RESULTS: Primiparity was significantly associated with higher frequency of sphincter lacerations (71 vs 43%, p=0.001). The patients of group A were with significantly higher weight than the patients of control group (67 vs 63 kg, p=0.036). Futhermore the BMI was different in the two groups (25,6 vs 23,4, p=0.003). There was a significant difference according to the length of the second part of labor (68 vs 48 min, p=0.037) and the posterior variety (32 vs 4%, p<0.001). The occurrence of shoulder dystocia was only just significant (6 vs 0%, p=0.052). Assisted-extraction is highly associated with perineal injuries (44 vs 1%, p<0.001). Futhermore the instrument has been concerned by the difference: Tarnier's forceps-assisted extraction (14 vs 1%, p=0.003), Suzor's forceps-assisted extraction (16 vs 0%, p=0.0005), Thierry's spatula-assisted extraction (14 vs 0%, p=0,0005). The association forceps and episiotomy has been found with higher frequency of perineal injury (43 vs 1%, p<0,0001). There were no difference between the 2 groups according fetal characteristics, type of analgesia, maternal age, gestational age, post-maturity or dose of ocytocin. DISCUSSION AND CONCLUSION: Primiparity is not the only risk factor of perineal injuries. Other risk factors have been found: assisted-extraction, occiput posterior fetal head position, and association episiotomy and assisted-extraction. Black origin seems to be protective.

[Fetal scalp pH: practical value during labour]. / pH au scalp foetal : intérêt pratique en salle de naissance.

Metabolic acidemia may cause cerebral palsy or perinatal death. Its detection is the major goal of perpartum fetal evaluation. Sensitivity of continuous fetal heart rate analysis is excellent, but the lack of specificity of this test can lead to inadequate intervention during labour. Fetal scalp pH is directly reliable to fetal acid-base status. In every situation where fetal heart rate displays ominous pattern, a potential acidemia can be detected with fetal scalp pH analysis. Intervention is recommended in the next 30min when fetal scalp pH is bellow 7.20. Complete analysis of fetal acid-base status parameters, including base excess and lactatemia allows a more precise detection of metabolic acidemia. Described since 1962, the place of fetal scalp pH analysis is still central in our daily practice.

[Microbiological exams and screenings during pregnancy]. / La surveillance microbiologique de la femme enceinte: quels examens réaliser durant la grossesse?

Infections due to bacteria, virus or parasites are frequent during pregnancy and can have severe consequences. Moreover, the vaginal carriage of commensal bacteria or dramatic changes in the equilibrium of the vaginal flora can induce complications and cause fetal contaminations. With the help of the guidelines set up by the French Agency of Accreditation and Evaluation in Health (Anaes), the authors detail the microbiological exams and screening which take part in the management of different situations at risk.

[Sudden death of neonates in the delivery room]. / Mort de nouveau-nés apparemment sains en salle de naissance: un problème de surveillance?

Healthy newborn death in the delivery room is uncommon. Unlike for sudden infant death syndrome well described in infants between 2 and 6 months of age, few publications have studied this event. We report two cases of asymptomatic term newborns who died unexpectedly in the delivery room. Noteworthy, these newborns were sleeping in prone position on their mother. The Agence Nationale d'Accreditation et d'Evaluation en Sante (ANAES) published recommendations to promote breast-feeding including uninterrupted early contact between the infant and his mother. However, immediately after birth, the newborn may be particularly vulnerable. The application of this recommendation unwisely could be dangerous for newborns allowed to stay on their mother without any monitoring, or medical supervision. We would like to point out the importance of healthy newborn supervision within the first hours of life that can be done without interfering with the mother-child bonding.

[Limits of antenatal management: technical and ethical aspects]. / Limites de la prise en charge anténatale: aspects techniques et éthiques.

The lower limit for elective delivery depends on technical and ethical issues. Elective delivery is usually accepted after 26 weeks gestation with a 60% survival rate and a 30% handicap rate. Decision making requires close coordination between obstetricians and pediatricians. Sufficient time must be devoted to providing the parents with adequate information. The physician plays a crucial role in decision making, but parent's information and consent are essential.

[Prevention of congenital toxoplasmosis in France. Risk assessment. Results and perspectives of prenatal screening and newborn follow up]. / La prévention de la toxoplasmose congénitale en France. Evaluation des risques. Résultats et perspectives du dépistage anténatal et du suivi du nouveau-né.

In France, a national program for the prevention of congenital toxoplasmosis has been set up 25 years ago. This program is here presented and discussed in details. It is based on a decision tree well defined, with pre and/or per gravidic serological screening with several different tests, completed, if necessary, by ultrasounds examinations of the fetus, biomolecular tests (PCR) on amniotic fluid, and by clinical, biological, and radiological surveillance of neo-nates. The purpose of this prevention program is to: 1/identify nonimmune young women and limit their contamination risk during pregnancy by appropriate counseling on hygiene and diet; 2/screen and treat per gravidic toxoplasmosis as early as possible so as to prevent or limit transmission to the fetus and its consequences. 3/in utero diagnose and treat infestation of the fetus; 4/diagnose and treat asymptomatic congenital toxoplasmosis in neonates, to prevent risks of reactivation and late complications, especially ocular. Such a prevention program has a cost validated by the prevalence of acquired toxoplasmosis in adults in France (over 50% of the population) and by the yearly incidence of congenital toxoplasmosis (at least 0.1% of births according to the best hypothesis). These 6 to 700 congenital toxoplasmosis cases per year may be compared to the 6 to 7,000 per gravidic seroconversions which could lead to fetal contamination if no preventive measures are taken. Nevertheless, as it is often the case in the field of prevention, it is very difficult to statistically assess the efficacy of this program even though several arguments show that it allows to eliminate the most serious toxoplasmosis, sources of serious handicaps at birth, and to limit the frequency of late complications (especially retino-choroiditis) of asymptomatic infections in neonates. The position of European countries varies as to prevention of congenital toxoplasmosis. Some countries (Austria, Belgium) have national prevention programs similar to the French one, whereas others have set up only limited programs or set up no systematic prevention. These differences may be accounted for by the different frequencies of toxoplasmic risk. It seems mandatory to forget all dogmatism and not to stick to a strictly statistical approach for a disease with not only medical but also social and human consequences.

[Fetal weight estimation during labour: comparison of the clinical and ultrasonographic approaches]. / Estimation du poids fœtal en salle de naissance: performances respectives de la clinique et de l'échographie.

OBJECTIVE: The estimation of the fetal weight is of major interest in many situations when the route of delivery has to be determined: breech presentations, diabetes and suspected macrosomia. The objective was to evaluate the accuracy of different methods for estimating fetal weight (EFW) during labour. A quality audit of the ultrasound images was also performed. PATIENTS AND METHODS: This was a prospective study performed in thirty patients at 37 weeks gestation or more, during the second stage of labour. The accuracy of clinical versus ultrasonographic (US) approach for EFW was tested (by two formulas according to Hadlock, with one that does not account head circumference [HC]). The ultrasound images' quality was also evaluated. RESULTS: The clinical assessment was significantly more accurate (-1 ± 8.5%) than the US approach using the formula with HC (-8 ± 9.8 %) (P<0.01). This difference was not found when choosing the formula without HC. Analysis of ultrasound images for abdomen and femur showed 74% and 89% of satisfactory measurements respectively, but only 43% for HC. CONCLUSION: These results did not demonstrate a superiority of the US over the clinical approach for EFW during labour. Taking into account the cephalic measurements appeared as a limitation of the accuracy of US formulas.

[Analysis of the evitability of intrapartum asphyxia with a peers review]. / Analyse de l'évitabilité de l'asphyxie per-partum par une revue de pairs.

OBJECTIVE: To assess the quality of intrapartum care in birth asphyxia cases. METHODS: Prospective analysis of all cases of birth asphyxia in nine maternity units during one year (2010). Birth asphyxia was defined as the combination of at least one clinical factor (Apgar≤7 at 5 minutes, signs of encephalopathy at birth) and at least one biological factor in cord (pH≤7, BD≥12 mmol/L, lactates>10 mmol/L). These cases were analyzed with a peer review from French guidelines 2007. RESULTS: Fifty cases of birth asphyxia were identified. After peer-review, they were defined as 46% non preventable, 27% possibly preventable, 24% definitely preventable and 3% not established. The main causes have been described as (i) misinterpretation of CTG during the first and second stages of labour, (ii) delayed response time to CTG anomalies and (iii) prolonged second stage. CONCLUSION: In half of the cases of birth asphyxia, this dreaded event was considered as preventable by a group of peers.

[Conservative management of a percreta placenta involving the omentum]. / Prise en charge conservatrice d'un placenta percreta impliquant l'épiploon.

We present the case of a percreta placenta involving the omentum, occurring in a patient with two uterine scars, diagnosed by chance during a scheduled caesarian. A conservative management of the uterus but radical for the placenta was made possible because of the invasion of the free edge of the omentum, not described in the literature until then. The postoperative course was uneventful. The question of the antanatal diagnosis and of the management of this potentially serious pathology is discussed in front of the international literature.

[Termination of pregnancy and intra-uterine fetal death after 14 weeks of pregnancy: Which protocol for induction of labour in 2010?]. / Interruptions médicales de grossesse et morts fœtales in utero après 14 semaines d'aménorrhée : quel protocole de déclenchement en 2010 ? Revue de la littérature.

UNLABELLED: The induction of labour for intra-uterine fetal death (IUFD) and termination of pregnancy (TOP) is a common obstetrical situation. The management of these specific inductions has improved. OBJECTIVES: Define a protocol that meets the several constraints of security, efficiency and cost for labor induction for IUFD and TOP. MATERIALS AND METHODS: Review. RESULTS: The protocol chosen uses the mifepristone 200mg by oral way on the first day for cervical preparation, completed by placing laminaria tents the evening of the 2nd day if the membranes are unreachable. On the 3rd day, in the birth room, the labor starts under analgesia, by using misoprostol 400 µg through vaginal way every 3 hours. Specific situations such as scarred uterus need modifications. CONCLUSION: Many protocols are described in the literature, they differ in their molecules, their dosages and their associations. This review offers a protocol that meets the announced objectives.

[Obstetrical care in gestational diabetes and management of preterm labor]. / Surveillance obstétricale en cas de diabète gestationnel et particularité de la prise en charge de la menace d'accouchement prématuré.

OBJECTIVES: Search for data necessary to elaborate recommendations for obstetrical care in gestational diabetes and management of preterm labor. METHODS: Systematic review of the literature and levels of evidence. RESULTS: In case of gestational diabetes and in the absence of disease or other risk factor associated, there is no evidence to support a systematic rate of clinical follow up different from other pregnancy. The relevance of ultrasound estimates of fetal weight is limited. No formula is superior to others or to the simple measurement of abdominal circumference for the prediction of macrosomia (EL3). The usefulness of the research septal hypertrophy is not demonstrated (EL4). The systematic application of umbilical Doppler has no proven benefits in the absence of growth restriction or hypertension associated (EL4). Monthly ultrasound monitoring of the fetus can be proposed for diabetics on insulin or poorly controlled. In cases of gestational diabetes controlled by diet, cardiotocography of fetal heart rate has not proven useful. In poorly controlled diabetes and/or on insulin, the registration may be discussed taking into account other risk factors associated (EL4). A weekly recording of fetal heart rate is often recommended in case of type 2 diabetes discovered during pregnancy. In case of preterm labor, calcium channel blockers and oxytocin antagonists can be used without specific precautions. The risk of using beta-adrenergic outweighs the benefit. Administration of corticosteroid can be done under glycemic control, with insulin therapy if necessary. Screening test for gestational diabetes should not be performed within few days after last steroid injection.

Obstetrical care in gestational diabetes and management of preterm labour.

AIM: To investigate data enabling the development of guidelines for obstetrical monitoring and management of the threat of preterm labour in gestational diabetes. METHODOLOGY: Systematic literature review. RESULTS: With gestational diabetes and the absence of other disorders or associated risk factors, there is no argument justifying a systematic clinical monitoring schedule different from other pregnancies. The relevance of ultrasound weight estimations is limited. No formula has emerged as being superior to the others or to the simple measurement of abdominal circumference for the prediction of macrosomia (EL3). The usefulness of testing for asymmetric septal hypertrophy has not been demonstrated (EL4). The routine performance of umbilical artery Doppler has no demonstrated utility in the absence of growth restriction or associated hypertension (EL4). Monthly ultrasound monitoring can be proposed for poorly-controlled diabetes or that requiring insulin. With gestational diabetes that is well-controlled with diet, foetal heart rate recording has no demonstrated use. The recording is debatable for poorly-controlled diabetes or that requiring insulin, while taking associated risk factors into consideration. Weekly recording of the foetal heart rate is often advised for type 2 diabetes diagnosed during pregnancy. If there is a threat of preterm labour, calcium channel blockers and oxytocin receptor antagonists may be used without special precautions. The risk-benefit ratio does not appear favourable for the ß2-adrenergic agonists. Lung maturation with corticosteroids may be done in parallel with glycaemic testing and insulin therapy if necessary. Diabetic screening tests should be done several days after the last injection of corticosteroid.