[Impact of prolonged second stage of labor on perinatal morbidity : what is our experience ?] / Impact d'un second stade de travail prolongé sur la morbidité périnatale : quelle est notre expérience?

OBJECTIVE: the management of the second stage of labor and its optimal duration are controversial, particularly for nulliparous women. Our aim is to analyze the impact of a prolonged second stage on perinatal morbidity in our institution. MATERIAL AND METHODS: this is a retrospective study conducted in the University Hospital of Liège (Belgium) from January to July 2019. The 160 patients included were divided into two groups according to the duration of the second stage and compared in terms of mode of delivery, maternal and neonatal morbidity. RESULTS: group 1 (85 %) had a second stage of labor inferior to 3 hours and group 2 (15 %) ? 3 hours. The cesarean deliveries for non-engagement of the fetus were significantly higher in group 2. No significant difference was observed in terms of maternal morbidity. The median Apgar score at 5 minutes was higher in group 1. The proportion of babies transferred to neonatal intensive care and to the neonatology department was higher in group 2. CONCLUSION: we mainly noted an increase in neonatal morbidity when the second stage exceeded 3 hours, which is consistent with literature where an increase in maternal morbidity is also described. Prolonging the second stage therefore seems inappropriate to us in the current state of knowledge.

OBJECTIFS: la gestion du second stade de travail et sa durée optimale sont controversées, particulièrement pour les patientes nullipares. Notre objectif est d'étudier l'impact d'un second stade prolongé sur la morbidité périnatale dans notre institution. Matériel et méthodes : il s'agit d'une étude rétrospective menée au CHU de Liège de janvier à juillet 2019. Les 160 patientes incluses ont été réparties en deux groupes en fonction de la durée du second stade et comparées en termes de mode d'accouchement, morbidité maternelle et néonatale. Résultats : le groupe 1 (85 %) présentait un second stade inf�rieur a 3 heures et le groupe 2 (15 %) ? 3 heures. Les césariennes pour non-engagement étaient significativement plus élevées dans le groupe 2. Aucune différence significative n'a été observée en termes de morbidité maternelle. Le score d'Apgar médian à 5 minutes était plus élevé dans le groupe 1. La proportion de bébés transférés au NIC («Neonatal Intensive Care¼) et en néonatologie était plus élevée dans le groupe 2. CONCLUSION: nous avons principalement noté une majoration de la morbidité néonatale lorsque le second stade dépassait 3 heures, ce qui rejoint la littérature où l'on décrit, également, une majoration de la morbidité maternelle. Prolonger le second stade nous semble, dès lors, inapproprié dans l'état actuel des connaissances.

[Velamentous cord insertion associated with vasa praevia]. / Le cas clinique du mois. Insertion vélamenteuse du cordon ombilical associée à un vasa praevia.

Velamentous cord insertion is a rare placental abnormality, that may be associated with vasa praevia, i.e. the presence of an umbilical vessel near the internal cervical orifice. In case of spontaneous rupture of the membranes, there is a major risk of fetal haemorrhage, which is often lethal for the unborn baby. The challenge of care is based on the prenatal diagnosis during the 2nd trimester ultrasound. In case a vasa praevia is confirmed during the 3rd trimester, elective caesarean section should be carried out prior to the onset of labour, between 34 and 36 weeks of pregnancy. Corticosteroid treatment for fetal lung maturation is recommended at 32 weeks of gestation because of the increased risk of preterm delivery. Velamentous cord insertion may be associated with other adverse pregnancy outcomes such as intrauterine growth restriction, death in utero, placental abnormalities.

L'insertion vélamenteuse du cordon ombilical est une anomalie placentaire rare, pouvant être associée à un vasa praevia, c'est-à-dire la présence d'un vaisseau ombilical en regard de l'orifice interne du col utérin. En cas de rupture spontanée des membranes, le risque d'hémorragie fœtale est majeur et, le plus souvent, létal pour l'enfant à naître. Le défi de la prise en charge est le diagnostic anténatal à l'échographie du 2ème trimestre. En cas de vasa praevia confirmé lors du 3ème trimestre, une césarienne doit être programmée avant la mise en travail spontanée, aux alentours de 34-36 semaines d'aménorrhée. Une cure de maturation pulmonaire par corticostéroïdes est recommandée à 32 semaines d'aménorrhée en raison du risque accru de prématurité. L'insertion vélamenteuse du cordon peut être associée à d'autres complications périnatales telles qu'un retard de croissance intra-utérin, une mort fœtale in utero, des anomalies placentaires.

[Elective induction of labor in nulliparous women : should we stop ?] / L'induction élective du travail chez la patiente nullipare : stop ou encore ?

In Wallonia, almost one fourth of cesarean sections are performed on nulliparous women with vertex nonanomalous singleton gestations who underwent induction of labor. The purpose of this study is to compare maternal and neonatal outcomes with elective induction of labor versus spontaneous onset of labor. Data for all deliveries at CHU de Liège over a two-year period were obtained. Women with vertex nonanomalous singleton gestations who delivered from 3900 to 40+6 weeks were selected. We tested the association of elective induction and operative vaginal delivery, cesarean section, post-partum hemorrhage, episiotomy and perineal lacerations, length of labor, length of stay, 1-min and 5-min APGAR inferior to 7 and admission to neonatal intensive care unit. Length of stay was significantly longer in all induced women. In nulliparous women, there was a 45 % probability of operative vaginal delivery or cesarean section delivery in those who underwent elective induction of labor. In light of these results, it seems that our policy of elective induction of labor in nulliparous women is causing unnecessary and potentially avoidable interventions.

En Wallonie, l'induction du travail chez les patientes nullipares avec grossesse singleton en présentation céphalique recrute près d'un quart de l'ensemble des césariennes réalisées. L'objectif de cette étude est de comparer le travail spontané et l'induction élective du travail en termes d'issues obstétricales et de morbidités maternelles et néonatales. Entre janvier 2015 et décembre 2016, les femmes ayant accouché entre 390 et 40+6 semaines d'aménorrhée (SA) au CHU de Liège et ayant présenté une grossesse singleton avec présentation céphalique, sans pathologie maternelle, gravidique ou fœtale ont été sélectionnées. Les variables suivantes ont été retenues : taux d'extraction instrumentale, taux de césarienne, type d'hémorragie du post-partum, état du périnée, durée du travail, durée d'hospitalisation, APGAR (1-5 min) défavorable (inf�rieur a 7) et passage en néonatologie. La durée d'hospitalisation est augmentée chez toutes les femmes induites. Chez les patientes nullipares, l'induction élective se solde, dans 45 % des cas, par une extraction instrumentale ou une césarienne en cours de travail. Nos pratiques d'induction élective chez les patientes nullipares pourraient être responsables d'un certain nombre d'interventions non nécessaires et évitables.

[How I explore intrauterine growth restriction]. / Comment j'explore le retard de croissance intra-utérin.

Intrauterine growth restriction (IUGR) is a common obstetrical condition (10 % of all pregnancies). Its origin is most often vascular, but it may also be a symptom of another fetal pathology (infectious, genetic, syndromic). Screening may be complicated due to the low sensitivity of the clinical examination as well as ultrasound. However, IUGR exposes the newborn to increased perinatal morbidity and mortality. In addition, various studies show that children born with low birth weight have a higher incidence of metabolic disorders in the long term. If an IUGR is discovered, an etiological development and management strategy must be carried out in a multidisciplinary manner.

Le retard de croissance intra-utérin est une pathologie obstétricale fréquente (10 %). Le plus souvent d'étiologie vasculaire, il peut cependant être le symptôme d'une pathologie fœtale autre (infectieuse, génétique, syndromique). Le dépistage peut être compliqué en raison d'une faible sensibilité, tant clinique qu'échographique. Il expose pourtant le nouveau-né à une morbi-mortalité périnatale augmentée à court terme. Par ailleurs, différentes études montrent que les enfants nés avec un faible poids présentent, à plus long terme, une incidence majorée de pathologies métaboliques. En cas de découverte d'un retard de croissance intra-utérin, une mise au point étiologique et une stratégie de prise en charge doivent être réalisées de façon multidisciplinaire.

[Congenital heart block revealing a maternal systemic disease : pathophysiology and therapeutic approaches]. / Bloc auriculoventriculaire congénital révélateur d'une pathologie maternelle systémique : physiopathologie et approches thérapeutiques.

Immunologic congenital atrioventricular block is due to the presence of anti-SSA and anti-SSB antibodies in maternal blood. This pathology is often diagnosed when the status is irreversible and is consequently associated with a high morbi-mortality. Close monitoring for high risk pregnancies can help to diagnose first and second degrees heart block and treatments can be offered when the block is still reversible. Fluorocorticoids, betamimetics and hydroxychloroquine use is not consensual. Studies are still in progress to prove their utility. We report the antenatal managing of a patient in which Goujerot-Sjögren disease was diagnosed after the revealing of an atrioventricular block in her fetus. After a brief physiopathological description, we present the current knowledge in preventive and curative treatments.

Le bloc auriculoventriculaire congénital d'origine immunologique est lié à la présence dans le sang maternel d'anticorps anti-SSA et anti-SSB. Le diagnostic est le plus souvent posé à un stade irréversible et est alors associé à une morbi-mortalité importante. La surveillance rapprochée des grossesses à risque permet de diagnostiquer des blocs de premier et deuxième degré et de proposer des traitements à un stade réversible de la maladie. L'utilisation de corticoïdes fluorés, de bêtamimétiques et de l'hydroxychloroquine n'est pas consensuelle. Des études sont toujours en cours pour valider leur utilité. Nous rapportons la prise en charge anténatale d'une patiente chez qui le diagnostic de syndrome de Goujerot-Sjögren a été posé suite à la découverte d'un bloc auriculoventriculaire chez son fœtus. Après un bref rappel physiopathologique, nous exposons l'état actuel des connaissances en ce qui concerne les traitements préventifs et curatifs.

[Alcohol, pregnancy and breast-feeding]. / Alcool, grossesse et allaitement.

Perinatal studies over the last ten years report that 3 % of pregnant women have alcohol consumption. The malformative and neurological consequences of prenatal exposure to alcohol have been known for more than 50 years. Research has shown that the effects of alcohol during pregnancy and breast-feeding go far beyond visible abnormalities at birth. Neurological consequences, from minor psychomotor retardation to severe behavioural disorders, make all the severity of this intoxication and justify strict instructions to refrain from taking alcohol during pregnancy and breast-feeding.

Les enquêtes périnatales réalisées au cours des dix dernières années rapportent que 3 % des femmes enceintes consomment de l'alcool. Les conséquences malformatives et neurologiques de l'exposition prénatale à l'alcool sont pourtant connues depuis plus de 50 ans et l'avancée des recherches a montré que les effets de l'alcool durant la grossesse et l'allaitement vont bien au-delà d'anomalies visibles à la naissance. Les conséquences neurologiques, du retard mineur aux troubles comportementaux sévères, illustrent toute la gravité de cette intoxication. Ils justifient une consigne stricte d'abstention de consommation d'alcool durant la grossesse et l'allaitement.

[Cushing's syndrome during pregnancy : diagnostic and therapeutic difficulties]. / Le cas clinique du mois. Syndrome de Cushing au cours d'une grossesse : difficultés diagnostiques et thérapeutiques.

Cushing's syndrome (CS), which is often associated with infertility, exceptionally occurs in pregnancy, and markedly increases maternal and fetal morbidity and mortality. Gestational CS may be challenging. Indeed, symptoms of hypercorticism may overlap with physiological hyperactivity of the hypothalamus-pituitary-adrenal axis in normal pregnancy. This case report describes a pregnant patient that underwent a fertility treatment and developed a gestational CS due to an adrenocortical adenoma. Diagnosis of gestational CS was suspected at 13 weeks by a new onset of hypokalemia and arterial hypertension. A multidisciplinary approach was necessary during follow up. At 24 weeks, laparoscopic surgery retrieved a 4 cm adrenocortical adenoma. Cesarean surgery was successfully practiced at 31 weeks, because of preeclampsia. We discuss the differential diagnosis of hypokalemia and arterial hypertension during pregnancy and the diagnosis and management of gestational CS.

Le syndrome de Cushing (SC), déterminant fréquemment une infertilité, survient exceptionnellement au cours d´une grossesse. La présentation du SC au cours de la grossesse s'accompagne d'une plus grande morbimortalité maternelle et foetale. Son diagnostic représente un véritable défi pour le clinicien, car les symptômes de l'hypercorticisme se superposent aux modifications physiologiques induites par la stimulation de l`axe corticotrope lors de la grossesse. Nous rapportons le cas d'une patiente enceinte après une fécondation in vitro. A 13 semaines de grossesse, un SC gestationnel d'origine surrénalienne est suspecté dans le cadre d'une hypokaliémie et d'une hypertension artérielle inaugurales. Un suivi multidisciplinaire est instauré au cours de la grossesse. Une surrénalectomie gauche par voie laparoscopique est décidée à 24 semaines d'aménorrhée, avec l'exérèse complète d'un adénome cortical, de 4 cm de diamètre. La chirurgie par césarienne est pratiquée avec succès à 31 semaines de grossesse, car la patiente développait une pré-éclampsie. Nous discutons les différents diagnostics différentiels d'une hypokaliémie et d'une hypertension artérielle au cours de la grossesse et les modalités de prise en charge d´un SC gestationnel.

[Vitamin D deficiency during pregnancy : what's the local situation ?] / Prévalence de l'hypovitaminose D chez la femme enceinte : quelle est la situation en région liégeoise ?

Vitamin D deficiency is a worldwide health problem, also during pregnancy. Inadequate maternal vitamin D status in pregnancy is associated with poor fetal growth, impaired bone development and rickets in infants after birth. Furthermore, higher rates of preeclampsia and gestational diabetes are associated with low maternal vitamin D status during pregnancy. Toxicity of vitamin D is rare. Most countries recommend vitamin D supplementation during pregnancy but guidelines are controversial and inadequate compared to real mother's and child's needs. Wath's the best strategy to follow and supplement mother during pregnancy? In a study carried out at the maternity clinic Notre-Dame des Bruyères (CHU Liège), we studied for a year the vitamin D concentrations of young women at start of pregnancy and of others after delivery to evaluate the local situation and management of vitamin D status during pregnancy. We did not collect the cord blood samples in this study. However, this is a project we would like to achieve soon. This would allow us to compare the vitamin D results of the mother at the time of delivery, to those of the cord blood of their respective child.

Les déficiences en vitamine D sont très répandues dans la population générale liégeoise, mais aussi chez la femme enceinte. Les ressources en vitamine D du nouveau-né sont complètement dépendantes de celles de sa mère. Les déficiences maternelles sont associées à un risque accru de rachitisme, de faible minéralisation osseuse, de naissance avant terme et de faible poids à la naissance chez l'enfant et de pré-éclampsie, de diabète gestationnel et d'accouchement par césarienne chez la mère. Les recommandations de supplémentation en vitamine D durant la grossesse sont très variées et semblent insuffisantes pour couvrir les besoins réels de la mère et de l'enfant. Quelle stratégie adopter pour un suivi correct et une supplémentation suffisante pendant la grossesse ? Dans une étude réalisée à la maternité de la clinique Notre-Dame des Bruyères (CHU Liège), nous avons étudié, pendant une année, les concentrations en vitamine D chez des jeunes femmes en début de grossesse et chez d'autres en fin de grossesse afin d'évaluer la situation locale et la prise en charge du statut en vitamine D pendant la grossesse. Nous n'avons pas récolté les échantillons de sang de cordon dans cette étude. Il s'agit cependant d'un projet que nous souhaiterions réaliser prochainement, ce qui nous permettrait de comparer les résultats en Vitamine D de la mère au moment de l'accouchement, à ceux du sang du cordon de leur enfant respectif.

Identifying maternal needs following childbirth: A qualitative study among mothers, fathers and professionals.

BACKGROUND: Pregnancy and childbirth are two critical stages in a woman's life. Various studies have suggested that psychological distress is common during the year after childbirth. The objectives of this exploratory study were (1) to explore the needs of mothers in the year following childbirth; (2) to compare these needs between mothers who did not have the feeling of living a psychological disorder or a depression and mothers who lived a psychological disorder or had the impression of living a depression; and (3) to compare the needs expressed by mothers with the perception of professionals and fathers about the mothers' needs. METHODS: First, we proceeded to 22 individual qualitative interviews followed by one focus group, with mothers, with and without experience of psychological distress. Then, we conducted 2 focus groups: one with professionals and one with fathers. RESULTS: Needs of mothers after childbirth have been indexed in four categories: need of information, need of psychological support, need to share experience, and need of practical and material support. Women do not feel sufficiently informed about this difficult period of life. They do not feel sufficiently supported, not only from a psychological point of view but also from a more practical point of view, for example with household chores. They need to share their experience of life, they need to be reassured and they need to feel understood. It seems that some differences exist between mothers' and professionals' experiences but also between mothers' and fathers' experiences. CONCLUSION: Young mothers apparently feel a lack of support at different levels in the year following childbirth. This study provides ways to meet women's needs and to try to prevent the risk of postpartum psychological distress during this period of time.

[Contribution of continuous glucose measurement in the management of gestational diabetes : a pilot study]. / Intérêt de la mesure continue du glucose dans la gestion du diabète gestationnel : une étude pilote liégeoise.

The prevalence of gestational diabetes increases as a result of universal screening, but also because of more stringent diagnostic criteria due to decreased set points. This diabetes can lead to severe complications for the offspring and / or for the mother. The management of a patient suffering from gestational diabetes is based on healthy diet and lifestyle advices. Iterative control of capillary glycemia is the usual way to monitor daily blood glucose. Continuous blood glucose measurement (CGM) provides reliable and comprehensive data over several days. Observing and interpreting the continuously recorded glucose concentration values should help to better understand the kinetics of glucose and to personalize the treatment. This preliminary study reports the results of 12 women with gestational diabetes and describes fluctuations of blood glucose levels all day long, particularly in the postprandial period. The CGM analysis shows that the maximum concentration of postprandial glucose is reached approximately 70 minutes after the morning and midday meals and 110 minutes after the evening meal.

La prévalence du diabète gestationnel augmente en raison d'un dépistage universel, mais aussi en raison de critères diagnostiques plus stricts, revus à la baisse. Ce diabète peut s'accompagner de complications pouvant être sévères pour l'enfant et/ou la mère. La prise en charge d'une patiente atteinte de diabète gestationnel repose sur les conseils hygiéno-diététiques adaptés et sur la surveillance des fluctuations glycémiques. En pratique habituelle, la surveillance glycémique quotidienne est réalisée via le contrôle itératif des glycémies capillaires. La mesure continue de la glycémie (MCG) offre l'avantage d'obtenir des données fiables et exhaustives sur plusieurs jours. Observer et interpréter les valeurs de concentration de glucose enregistrées de manière continue permettraient de mieux appréhender la cinétique du glucose et, idéalement, de personnaliser l'approche thérapeutique. Ce travail préliminaire rapporte les résultats observés chez 12 patientes présentant un diabète gestationnel et décrit les fluctuations du glucose au cours du nycthémère, particulièrement en période postprandiale. L'analyse de la MCG démontre que la concentration maximale de glucose postprandial est atteinte aux alentours de 70 minutes après le repas du matin et du midi et 110 minutes après le repas du soir.

Molecular imaging as a tool to investigate heterogeneity of advanced HER2-positive breast cancer and to predict patient outcome under trastuzumab emtansine (T-DM1): the ZEPHIR trial.

BACKGROUND: Only human epidermal growth factor receptor (HER)2 status determined by immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) has been validated to predict efficacy of HER2-targeting antibody-drug-conjugate trastuzumab emtansine (T-DM1). We propose molecular imaging to explore intra-/interpatient heterogeneity in HER2 mapping of metastatic disease and to identify patients unlikely to benefit from T-DM1. PATIENTS AND METHODS: HER2-positive mBC patients with IHC3+ or FISH ≥ 2.2 scheduled for T-DM1 underwent a pretreatment HER2-positron emission tomography (PET)/computed tomography (CT) with (89)Zr-trastuzumab. [(18)F]2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT was performed at baseline and before T-DM1 cycle 2. Patients were grouped into four HER2-PET/CT patterns according to the proportion of FDG-avid tumor load showing relevant (89)Zr-trastuzumab uptake (>blood pool activity): patterns A and B were considered positive (>50% or all of the tumor load 'positive'); patterns C and D were considered negative (>50% or all of the tumor load 'negative'). Early FDG-PET/CT was defined as nonresponding when >50% of the tumor load showed no significant reduction of FDG uptake (<15%). Negative (NPV) and positive predictive values (PPV) of HER2-PET/CT, early FDG response and their combination were assessed to predict morphological response (RECIST 1.1) after three T-DM1 cycles and time-to-treatment failure (TTF). RESULTS: In the 56 patients analyzed, 29% had negative HER2-PET/CT while intrapatient heterogeneity (patterns B and C) was found in 46% of patients. Compared with RECIST1.1, respective NPV/PPV for HER2-PET/CT were 88%/72% and 83%/96% for early FDG-PET/CT. Combining HER2-PET/CT and FDG-PET/CT accurately predicted morphological response (PPV and NPV: 100%) and discriminated patients with a median TTF of only 2.8 months [n = 12, 95% confidence interval (CI) 1.4-7.6] from those with a TTF of 15 months (n = 25, 95% CI 9.7-not calculable). CONCLUSIONS: Pretreatment imaging of HER2 targeting, combined with early metabolic response assessment holds great promise for improving the understanding of tumor heterogeneity in mBC and for selecting patients who will/will not benefit from T-DM1. CLINICALTRIALSGOV IDENTIFIER: NCT01565200.

[Vaginal delivery of bi-scarred uterus]. / L'accouchement par voie basse sur utérus bi-cicatriciel.

Despite awareness of obstetricians to the constant increase in the number of caesarean sections in recent years, certain dogmas concerning uterine scar still persist in our practices and influence clinical decisions. Fear of a uterine scar rupture, a major obstetric complication, is always in mind. As for bi-uterine scar, it was considered, until recently in Belgium, as a full and definitive indication against an attempted vaginal delivery. However, several previous clinical studies clearly showed that, under certain conditions, vaginal birth after two caesarean sections was usually successful with very good results in terms of maternal and fetal morbidities. Even if such a clinical situation is not common, this article aims to sensitize obstetricians to the lack of objective clinical arguments to reject a vaginal delivery in a patient having a previous history of two caesarean sections. Such a patient must be motivated and followed up within a specific framework. Moreover, this type of delivery should receive optimal monitoring.

Résumé : Malgré la sensibilisation des obstétriciens à l'augmentation constante du nombre de césariennes ces dernières années, certains dogmes concernant l'utérus cicatriciel persistent encore dans nos pratiques et influencent les décisions du praticien. La peur d'une rupture de cicatrice utérine, complication obstétricale majeure, reste toujours présente à l'esprit. Quant à l'utérus bi-cicatriciel, ce dernier était considéré, jusque il y a peu dans notre pays, comme une contre-indication totale et définitive à une tentative d'accouchement par voie basse. La littérature nous apprend pourtant que plusieurs études observationnelles ont montré que, sous certaines conditions, une tentative d'accouchement par voie basse après deux césariennes était le plus souvent couronnée de succès, avec de très bons résultats en ce qui concerne la morbidité maternelle et foetale. Même si pareille situation clinique n'est pas fréquente, le but de cet article est de sensibiliser les obstétriciens au manque d'arguments cliniques objectifs pour refuser un accouchement par voie basse chez une patiente ayant deux antécédents de césarienne, à condition que la demande soit motivée et rentre dans un cadre bien précis. Ce type d'accouchement doit bénéficier d'une surveillance optimale.

[A case of fetal death resulting from a massive fetomaternal hemorrhage]. / LE CAS CLINIQUE DU MOIS. Mort foetale in utero due à une hémorragie foeto-maternelle massive.

We report the case of a late stillbirth which unexpectedly occurred in a patient without any medical history and after a meticulous obstetrical follow up. Stillbirth is unfortunately not unusual and implies a complete etiological work up. In the present observation, the Kleihauer test and anatomoclinical examination concluded that the death was due to an acute cerebral anoxy resulting from a massive fetomaternal hemorrhage (HFM). HFM is rarely considered as the cause of a late stillbirth, but its occurrence is certainly underestimated. Yet, if HFM is identified before fetal death, an .adequate management could considerably improve the fetal prognosis and, sometines, save the child's life.

[Threatened preterm delivery managed in a university medical center devoted to high risk pregnancies: assessment of daily practice in relation to international guidelines]. / La menace d'accouchement prémature. Prise en charge dans un service universitaire de grossesses à risque : évaluation de la pratique clinique comparée aux recommandations internationals.

Premature birth poses a real problem of public health. As the principal cause of foetal ill-health and perinatal mortality, it generates high healthcare costs. By seeking to prevent early labour and to deal with its causes, a good obstetrical practice can reduce its negative impact, both medical and financial, on society. This article describes the results of a study of threatened preterm delivery admissions at the Citadelle hospital in Liege during the year 2012. The findings are compared to international guidelines with a view to identify aspects that could be improved.

The long and winding road to biomarkers for immunotherapy: a retrospective analysis of samples from patients with triple-negative breast cancer treated with pembrolizumab.

BACKGROUND: Immune checkpoint blockade (ICB) in combination with chemotherapy improves outcome of patients with triple-negative breast cancer (TNBC) in metastatic and early settings. The identification of predictive biomarkers able to guide treatment decisions is challenging and currently limited to programmed death-ligand 1 (PD-L1) expression and high tumor mutational burden (TMB) in the advanced setting, with several limitations. MATERIALS AND METHODS: We carried out a retrospective analysis of clinical-pathological and molecular characteristics of tumor samples from 11 patients with advanced TNBC treated with single-agent pembrolizumab participating in two early-phase clinical trials: KEYNOTE-012 and KEYNOTE-086. Clinical, imaging, pathological [i.e. tumor-infiltrating lymphocytes (TILs), PD-L1 status], RNA sequencing, and whole-exome sequencing data were analyzed. We compared our results with publicly available transcriptomic data from TNBC cohorts from TCGA and METABRIC. RESULTS: Response to pembrolizumab was heterogeneous: two patients experienced exceptional long-lasting responses, six rapid progressions, and three relatively slower disease progression. Neither PD-L1 nor stromal TILs were significantly associated with response to treatment. Increased TMB values were observed in tumor samples from exceptional responders compared to the rest of the cohort (P = 3.4 × 10-4). Tumors from exceptional responders were enriched in adaptive and innate immune cell signatures. Expression of regulatory T-cell markers (FOXP3, CCR4, CCR8, TIGIT) was mainly observed in tumors from responders except for glycoprotein-A repetitions predominant (GARP), which was overexpressed in tumors from rapid progressors. GARP RNA expression in primary breast tumors from the public dataset was significantly associated with a worse prognosis. CONCLUSIONS: The wide spectrum of clinical responses to ICB supports that TNBC is a heterogeneous disease. Tumors with high TMB respond better to ICB. However, the optimal cut-off of 10 mutations (mut)/megabase (Mb) may not reflect the complexity of all tumor subtypes, despite its approval as a tumor-agnostic biomarker. Further studies are required to better elucidate the relevance of the tumor microenvironment and its components as potential predictive biomarkers in the context of ICB.

[Addictions and pregnancy : how to ruin a pregnancy]. / Assuétudes et grossesse: comment détruire un projet de naissance.

Pregnant women are well aware that any addiction during pregnancy can be harmful to the child. In spite of this knowledge, many continue to smoke, to drink alcohol, to consume illicit drugs or to absorb medicines because these dependences are particularly strong. Tobacco, alcohol, cocaine and ecstasy represent the most dangerous substances as regards foetal damage. The period of pregnancy is the optimal moment to stop these addictions. It is therefore essential to raise awareness among the general public, policy makers, and physicians of the fact that addictions during pregnancy cause a disparity in terms of future health and life expectancy of the unborn child.

[Management of gestational diabetes]. / Prise en charge du diabète gestationnel.

Pregnancy is associated with relative carbohydrate intolerance and insulin resistance. Gestational diabetes mellitus (GDM) is recognized as a risk factor for a number of adverse outcomes during pregnancy, including excessive fetal growth, increased incidence of birth trauma and neonatal metabolic abnormalities. This recognition has led to recommendations to screen all pregnant women for GDM and to treat those whose glucose tolerance tests exceed threshold criteria. Numerous epidemiological studies show that GDM affects between 1 and 25% of pregnancies, depending on the ethnicity of the population studied and the diagnostic criteria. Intervention to change lifestyle and, if maternal hyperglycemia persists, treatment with additional oral medication or insulin injections have shown to improve perinatal outcomes. Patients with GDM have a high risk of developing type 2 diabetes in the years after delivery and these women are encouraged to practice specific health behaviours (dietary habits, physical activity) during the postpartum period. The present article discusses the management of GDM in the light of data from the latest studies and international recommendations.

Serial FDG-PET/CT for early outcome prediction in patients with metastatic colorectal cancer undergoing chemotherapy.

BACKGROUND: The study purpose was to assess the predictive value of 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET)/computerized tomography (CT) metabolic response after a single course of chemotherapy in patients with metastatic colorectal cancer (mCRC). PATIENTS AND METHODS: FDG-PET/CT scans were carried out at baseline and on day 14 in 41 patients with unresectable mCRC treated with a biweekly regimen of chemotherapy. Metabolic nonresponse was defined by <15% decrease in FDG uptake in the dominant proportion of the patient's lesions or if a lesion was found metabolically progressive. The PET-based response was correlated with radiological response (primary end point) and patient's outcome (secondary end points). RESULTS: RECIST response rate in metabolically responding patients was 43% (10 of 23) compared with 0% (0 of 17) in nonresponding patients (P=0.002). The metabolic assessment's predictive performance for RECIST response was sensitivity 100% [95% confidence interval (CI) 69% to 100%], specificity 57% (95% CI 37% to 75%), positive predictive value 43% (95% CI 23% to 66%), and negative predictive value 100% (95% CI 80% to 100%). Comparing metabolically responding versus nonresponding patients, the hazard ratio (HR) was 0.28 (95% CI 0.10-0.76) for overall survival and 0.57 (95% CI 0.27-1.21) for progression-free survival. CONCLUSION: The metabolic response measured by FDG-PET/CT after a single course of chemotherapy in mCRC is able to identify patients who will not benefit from the treatment.

[Pregnancy and systemic lupus erythematosus: compatible?]. / Lupus erythémateux systémique et grossesse: incompatibles?

Systemic lupus erythematosus (SLE) is a chronic, multisystem autoimmune disease that predominantly occurs in women of childbearing age. The risk of obstetric complications in lupus parturients is significant. In addition, pregnancy may be associated with flares of the disease requiring immunosuppressive therapy. For these reasons, SLE pregnancies are considered high risk and involve careful collaboration of the obstetrician and rheumatologist. Through the latter and medical advances including a better and better understanding of the binomial mother-child, most pregnancies end in a success.

[Screening strategy and diagnostic criteria for gestational diabetes. Proposals of the GGOLFB]. / Stratégie de dépistage et critères diagnostiques du diabète gestationnel. Propositions du GGOLFB.

For nearly 50 years, the strategy of screening and the diagnostic criteria for gestational diabetes have been the subject of endless controversies. They differ between countries and from one center to another, mainly because of the lack of hard data allowing to define glycemic thresholds at which a therapeutic management is needed. Recently, a large observational study has demonstrated the existence of a robust relationship between maternal blood sugar and several fetomaternal perinatal complications. This relationship is linear, with no clear threshold that would define gestational diabetes unambiguously. Meanwhile, two randomized intervention trials have shown that the therapeutic management of mild gestational diabetes was associated with improved perinatal outcomes. Based on these data, the "International Association of Diabetes and Pregnancy Study Group" (IADPSG) released new recommendations on screening methods and diagnostic criteria for gestational diabetes. Although already endorsed by several international associations and implemented in some countries, these recommendations still raise questions and criticisms. This is why the "Groupement des Gynécologues Obstétriciens de Langue Française de Belgique" (GGOLFB) organized a meeting between diabetologists and gynecologists which allowed to reach a consensus on the strategy that we intend to implement in our respective centers. The purpose of this paper is to briefly overview the recent advances in gestational diabetes and more particularly to make our key conclusions known to the medical community. This will enable the standardization of the management of gestational diabetes in the French-speaking part of Belgium.