Intravenous nitroglycerin for internal podalic version of the second twin in transverse lie.

OBJECTIVE: To report our experience with high doses (0.1-0.2 mg per 10 kg pregnant weight) of intravenous (IV) nitroglycerin as a uterine relaxing agent for managing internal podalic version of the second twin in transverse lie with unruptured membranes. METHODS: Between August 1994 and December 1997, we managed 22 cases of internal podalic version of the second twin with the administration of high doses of IV nitroglycerin. RESULTS: Twenty internal podalic versions were completed successfully, and two cases failed. One failure was considered not related to IV nitroglycerin because the patient had a panic attack, requiring general anesthesia for sedation. The internal podalic version then succeeded. The patient with true failure of IV nitroglycerin required emergency cesarean because of acute fetal bradycardia and a nonrelaxed uterus. This was the only nontransverse lie, but with a very high face presentation. One internal podalic version was complicated by hemorrhage (2000 mL). CONCLUSION: Intravenous nitroglycerin to induce uterine atonia, with epidural analgesia, avoids general anesthesia and makes internal podalic version easier. In 22 cases (with success in 20) of internal podalic version of the second twin in transverse lie with unruptured membranes, IV nitroglycerin induced transient and prompt uterine relaxation without affecting maternal and fetal outcomes.

Pre-eclampsia: physiology and immunological aspects.

Pre-eclampsia is a frequent, unpredictable syndrome which is dangerous for both mother and foetus. The concept of placental ischemia has gained wide acceptance among the numerous theories put forward to explain the illness. The setting up of preeclampsia seems to be scheduled in two steps: (1) an absolute or relative placental ischemia due to vascular diseases or hypertrophic placenta, or most often secondary to implantation defect, particularly anomaly with the invasive trophoblast; (2) a diffuse endothelial disease. The connection between these two steps is incompletely disclosed. The authors demonstrate that the maternal immune system which is strongly stressed during all the stages of normal gestation is implicated in pre-eclampsia. Its role is probably not univocal. Foeto-trophoblastic antigens could be poorly recognised. This defect of recognition could lead to the abnormalities of trophoblastic invasion observed in pre-eclampsia. Pre-eclampsia does not seem to be accompanied by an immunological rejection of the foetus. Some genetically predisposed patients do not have a sufficiently competent immune system to neutralise one or more of the toxic products released by the ischemic placenta. Certain types of pre-eclampsia could be auto-immune, with the auto-antibodies directed against certain types of phospholipids or trophoblastic constituents. A disequilibrium between oxidation and anti-oxidation mechanisms involving neutrophils could lead to aggression of the endothelium which is observed in pre-eclampsia. Pre-eclampsia could represent a form of immuno-dystrophy, with the excessive production of adverse cytokines locally, directed against the trophoblast. Without directly implicating the immune system as the trigger of pre-eclampsia, it seems that its role is unclear. In some cases it develops protective mechanisms which, when overwhelmed or inadequate, allows pre-eclampsia to occur. In other cases it can form part of the cascade of aggressions leading to the abnormalities encountered. The integration of these abnormalities in the pathophysiological models, could help improve the classification of pre-eclampsia. This attempt will lead to a more adapted preventive and therapeutic management of pre-eclampsia.

Immunological aspects of ovarian function: role of the cytokines.

Interaction between the immune system and reproduction is multiple. Either directly or indirectly through their products, immune cells are associated with the regulation of every level of the hypothalamus-pituitary-ovarian axis. Immune cells are present in the ovaries and their numbers increase during the cycle. During the follicular development cytokines assist granulosa cell growth while inhibiting their differentiation. During the LH peak, an influx of immune cells occurs and several cytokines are released. The rupture of the follicle is considered as an inflammatory reaction. IL-1, TNF-alpha are the main cytokines involved in this process. During the luteal phase, the installation of the corpus luteum needs the setting up of neovascularization. Cytokines are probable candidates for this function, but they also promote cellular differentiation resulting in steroid synthesis. In the absence of pregnancy T lymphocytes and eosinophils are involved in corpus luteum regression. Their products are directly cytotoxic for the luteal cells. They attract macrophages which are locally activated to phagocytose the damaged luteal cells. They can induce apoptosis of endothelial and luteal cells through gene expression. Cytokines are members of a larger regulatory network residing in the ovary and involving hormones and growth factors. The various stages of ovarian cycle will be shown from an immunological point of view. Understanding the role of the cytokines should enable us to go beyond a purely descriptive stage, and allow us to envisage new ovulation induction therapy and treatment in certain cases of premature menopause.

Myotonic dystrophy and pregnancy. A report of two cases and a review of the literature.

Myotonic dystrophy is a rare disease (1/8000), that is rarely associated with pregnancy, due to the fact that parents carrying the disease often encounter hypogonadism. Myotonic dystrophy is a neuro-endocrinian 'heredo-degenerative' dystrophy, with dominant autosomic transmission. Its association with pregnancy can lead to several problems. The myotony is often aggravated which leads to obstetrical complications turning into fetal loss, premature term delivery, hydrops, in-utero death, difficulties in expulsion, haemorrhage during delivery and/or anaesthetic accidents. The following signs during the pregnancy can diagnose fetal damage: presence of a hydrops, rare active fetal movements, and low fetal cardiac rhythm. They signify serious fetal damage leading to a diagnosis of myotonic dystrophy. Personal and family antecedents as well as an important hypotony and respiratory distress discovered in the new born are equally evocative elements. In congenital cases (6-30% of the time) the prognosis of the child is pessimistic. For all of the above elements, transmission is of maternal origin. The diagnosis of the congenital form is difficult because the disease is often unknown by the mother. The appearance of molecular tools permits a diagnosis to be formed much more rapidly in a new-born suspected to carry the illness of neonatal Steinert. Two observations illustrate this pathology. The occurrence of congenital myotonic dystrophy in a new-born allows us to diagnose the disease within the mother.

Fetal macrosomia: risk factors and outcome. A study of the outcome concerning 100 cases >4500 g.

OBJECTIVE: Because difficult vaginal delivery is more frequent with macrosomic fetuses, some authors recommend routine caesarean section for the delivery of fetuses >4500 g. The purpose of this study was to evaluate the appropriateness of this recommendation, in particular, to analyze maternal and fetal complications according to the mode of delivery. METHOD: Maternal and neonatal records of 100 infants with weights of at least 4500 g were identified retrospectively from January 1991 to December 1996. Outcome variables included the mode of delivery and the incidence of maternal and perinatal complications. RESULTS: The study sample consisted of 100 infant and mother pairs. Macrosomic fetuses represented 0.95% of all deliveries during this period and only ten were >5000 g. Mean birth weight was 4730 g (maximum, 5780 g). Gestational diabetes was present in nineteen patients. Diabetes was present in three patients. A trial of labour was allowed in 87 women, and elective caesarean delivery was performed in thirteen patients. The overall cesarean rate, including elective caesarean delivery and failed trial of labour, was 36%. Of those undergoing a trial of labour, 73% (64/87) delivered vaginally. Shoulder dystocia occurred fourteen times (22% of vaginal deliveries) and it was the most frequent complication in our series. There were five cases of Erb's palsy, one of which was associated with humeral fracture, and four cases of clavicular fracture. By three months of age, all affected infants were without sequelae. There was no related perinatal mortality and only two cases of birth asphyxia. Maternal complications with vaginal delivery of macrosomic infants included a high incidence of lacerations requiring repair (eleven cases). No complications were noticed in the patients who had a caesarean section. CONCLUSION: Vaginal delivery is a reasonable alternative to elective cesarean section for infants with estimated birth weights of less than 5000 g and a trial of labour can be offered. For the fetuses with estimated birth weight >5000 g, an elective caesarean section should be recommended, especially in primiparous women.

Monoamniotic twin pregnancies. Review of the literature, and a case report with vaginal delivery.

OBJECTIVE: To specify the process of the sometimes difficult diagnosis of monoamniotic twin pregnancies, as well as the best practise for delivery of this type of pregnancy. METHOD: Using their personal observation (a patient with a monoamniotic twin pregnancy, which presented a vaginal delivery at 35 weeks of gestation, two girls, in cephalic presentation, without particular problem, despite an entanglement of the cord and the existence of a knot), the authors established a review of the literature on this subject. RESULTS: Monoamniotic twin pregnancies represent a rare possibility. The prognosis is traditionally somber: 40-60% mortality, mainly due to pathologies of the cord. The review of the recent literature shows that most authors remain in favour of weekly ultrasound supervision from the 23rd week and of caesarean section in principle at 34 weeks (or from fetal pulmonary maturation). CONCLUSION: In the absence of funicular compression signs by colour-doppler, and under the cover of flawless obstetrical conditions, vaginal delivery can only be authorized for cases when both presentations are cephalic.

Pregnancy after myocardial infarction.

UNLABELLED: The occurrence of pregnancy in a patient after myocardial infarction remains a dilemma for both the cardiologist and the obstetrician. The majority of obstetricians and cardiologists are very reticent about pregnancy in a woman suffering from coronary disease. AIMS: The aims of this study are to evaluate the risks, the prognosis of pregnancy for women who had suffered from myocardial infarction and to propose guidelines for pre-pregnancy counselling and medical supervision of the pregnancy and delivery. METHODS: A review of literature has revealed 30 cases, 14 of which are sufficiently documented. Only one of these patients requested pre-pregnancy counselling. We add to this experience the case of a patient who, having had an infarction, was authorized to begin pregnancy. RESULTS: Most of the pregnancies in these patients evolve satisfactorily if the more frequent cardiovascular complications are diagnosed and treated rapidly. During the pregnancy, rest is the rule and any situation which risks to increase the myocardial work-load should be avoided. Normal vaginal delivery with epidural anesthesia is the preferred method. CONCLUSION: The maternal and fetal prognosis is good on condition of performing a pre-pregnancy examination and of setting up a multi-discipline surveillance of the pregnancy. The review of the literature does not confirm the surrounding pessimism concerning the patients becoming pregnant after myocardial infarction.

Intravenous nitroglycerin for intrapartum internal podalic version of the second non-vertex twin.

OBJECTIVE: Authors report their experience of intravenous nitroglycerin as uterine relaxing agent for managing successfully internal podalic version of the second twin. METHODS: From a retrospective study including nine observations of internal podalic version of the second non vertex twin performed with administration of intravenous nitroglycerin, between August 1994 and February 1996, authors compare their results with those reported elsewhere. RESULTS: Two failures of internal podalic version with nitroglycerin have been observed. But one failure is not considered to be due to the NTG: it was a patient, who had a panic attack necessitating a general anesthesia for sedative purpose. The internal podalic version succeeded. The true failure of NTG needed an emergency cesarean due to acute fetal distress and a non relaxing uterus. One internal podalic version was complicated by hemorrhage. The intravenous NTG used to induce uterine atonia associated with epidural-analgesia to relief pain avoiding general anesthesia makes internal podalic version easier. CONCLUSION: Our results confirmed those already reported. That intravenous nitroglycerin (NTG) injection induces a transient and prompt uterine relaxation required for internal podalic version without affecting maternal and fetal prognosis.

Varicella and pregnancy.

OBJECTIVE: To appreciate the risk of embryo-foetopathy in case of maternal varicella occurring before 20 weeks of gestation, as well as the maternal complication risk (notably pulmonary) in case of maternal varicella occurring the third trimester of pregnancy. METHOD: Over the period from January 1987 to February 1995, 20 patients were managed for maternal varicella confirmed during the pregnancy. From these observations, the authors, by studying the literature, attempt to better specify the real fetal and/or maternal complication risk in case of maternal varicella. RESULTS: In their personal series of 20 cases, including 17 before 20 weeks of gestation, the authors have noted no embryo-foetopathy. Similarly, no maternal complication (notably pulmonary complication), has been found. Careful study of the literature allows to specify some points. In case of varicella before 20 weeks, one observes an identical frequency of spontaneous abortions, as compared to the general population and a moderated increase of the frequency of premature delivery. The risk of congenital varicella syndrome reaches about 1.3%. Finally the risk of neonatal varicella consists in a maternal infection which occurs during the perinatal period and which is source of a high perinatal morbidity. The prenatal diagnosis is based essentially and currently, on the amniocentesis with viral research by polymerase chain reaction (PCR) in the amniotic fluid, completed by a ultrasound supervision. CONCLUSION: The occurrence of maternal varicella during the pregnancy is rare (0.7/1000) because more than 90% of women are immunized. The risk of congenital varicella syndrome is limited to the 20 first weeks and seems very weak, authorizing therapists to reassure patients presenting a varicella during their pregnancy. Nevertheless, the risk of pulmonary complications for the mother, in case of varicella during the third trimester, does exist and requires appropriated treatment.

[Marfan syndrome and pregnancy. Apropos of 4 cases]. / Syndrome de Marfan et grossesse. A propos de quatre cas.

OBJECTIVES: To create a follow-up protocol for pregnant patients with Marfan syndrome. PATIENTS AND METHODS: We retrospectively reviewed the charts of patients who delivered in the Jeanne de Flandre University Hospital between June 1996 and June 1999. Four pregnant patients with Marfan syndrome were identified. RESULTS: Three of these patients had Bentall procedure. One of them had vaginal delivery and the two others underwent cesarean section. One of these two patients developed aortic valve thrombus at 14 weeks of amenorrhea. The fourth patient did not have surgery and had two vaginal deliveries. DISCUSSION: According to our results and after reviewing literature pregnant patients with Marfan syndrome were divided into two groups. The 1st group was comprised of patients who underwent Bentall procedure. The 2nd one was comprised of patients who did not undergo any surgical procedure. The possibility of vaginal delivery for patients who underwent Bentall procedure (one case) and the interest of Propanolol and anticoagulant treatment are emphasized. CONCLUSION: The multivariant approach of pregnant patients with Marfan syndrome is stressed out with special reference to the potential complications of this syndrome such as aortic dissection and to the problems related to the anticoagulant treatment.

[Ultrasonic diagnosis of placenta percreta. Apropos of a case with hemorrhagic complication]. / Diagnostic ultrasonore du placenta percreta. A propos d'une complication hémorragique.

Placenta percreta is a rare but severe disease, which is more and more frequent. The reported case shows that diagnosis can be made with B mode and color Doppler ultrasonography. Extension of high-vascularized placenta to the myometrium, abnormal placental-subplacental complex and vascular flow through the myometrium were suggestive of the diagnosis. Early diagnosis should decrease mortality and morbidity.

[Immunological recognition in pregnancy: physiology]. / Reconnaissance immunologique de la grossesse: physiologie.

In the last decade works on the responses of the mother's immune system to the presence of the feto-placental unit have burgeoned. The antigens that are presented to the mother are special because the trophoblast does not show classical transplantation antigens which are classically implicated in graft rejection. A class I antigen, antigen HLA-G is present in the extra-villous cytotrophoblast, different from classical antigens by virtue of its molecular weight and its reduced antigenic polymorphism. Many functions have been attributed to this antigen; most of them are still being evaluated. The most important immunological phenomena are found at the feto-placental interface. Several events occur simultaneously or successively. Recognition of the trophoblast brings about an inflammatory reaction which is the initial phase of graft rejection. The numerous cytokines that are produced in this initial phase allow decidualization to occur and for the embryo to implant when it has reached an adequate stage of evolution. Rapidly, immunosuppressant mechanisms stop this rejection reaction which if not stopped can cause the pregnancy to end. There is a delicate equilibrium between the different cytokines, those favourable to pregnancy and those damaging to pregnancy. The trophoblast which is resistant to factors which would cause rejection protects the fetus particularly if its growth is helped along by certain cytokines. On the other hand, other cytokines are prejudicial to the growth of the trophoblast and activate certain cytotoxic cells which become aggressive. The maternal immune system and the endocrine system work together to maintain this cytokine network which if destabilized leads to certain pathological situations. Disturbances can be due to poor maternal recognition particularly if the trophoblast does not give out good antigens, or if the mother is genetically programmed not to respond although the disturbance can come from external factors such as certain infections.

[Receiver operating curve, an aid in decision making. Principles and applications illustrated with some examples]. / La courbe R.O.C. (receiver operating curve), une aide à la décision. Principes et applications à travers quelques exemples.

The practitioner has many difficult questions to resolve when he has placed in front of him more and more diagnostic and screening tests. Which is, in a given situation, the best test, by which is meant useful, least costly and most acceptable by the patient? Having chosen the test, at what level is the result to be considered positive or negative? The authors, having explained the principles and having taken some examples out of the literature of gynaecology and obstetrics, present a technique that shows on a receiver operating characteristic curve sensitivity and specificity sharing as a function of the possible levels for making decisions according to the test. The curve inordinate shows the sensitivity of the test or the number of true positives and on the abscissa the complement of specificity or the rate of false positives ford each decision threshold of the test. A simple glance gives the practitioner a view of the characteristics of the test over the whole band that this test can use. Using these curves it is possible to adopt more elaborate techniques to select the best threshold and to compare different tests.

[Evaluation of the defense mechanisms of the body during pregnancy. Clinical and experimental aspects]. / Evaluation des défenses de l'organisme pendant la grossesse. Aspects cliniques et expérimentaux.

The authors, in clinical, epidemiological and experimental studies, point to the extent to which defence mechanisms are depressed during pregnancy. Viral, parasitic and bacterial infections are more common and more serious in pregnancy; but it does not seem to be possible to speak of an immunodeficient syndrome that is acquired in pregnancy. The nutritional and hormonal status as well as racial and geographical factors have their effects on numbers of defense mechanisms. The immune system cannot be relied on in these changes of the defences entirely, insofar as the arrival of antibiotics has had a big effect on the consequences of pregnancy.

[Non-specific immune defenses present in pregnancy]. / Les défenses immunitaires non spécifiques pendant la grossesse.

The state of pregnancy changes the immune system by allowing the trophoblast to go on developing without letting the mother's body be invaded by it, and by keeping intact immune defences against the usual assaults. The non specific immune system is the first bulwark against invaders. The elements of this system, which do not depend on immunological memory, are: the macrophage-monocyte system, Natural Killer cells (NK), the complement component and other bactericidal substances such as lysozyme, fibronectin and interferon. Pregnancy improves the working of the monocyte-macrophage system. In fact, the macrophages of th reticulo-endothelial system, which can be found in different strategic places in the body, phagocytose abnormal particles more intensely. The monocytes in the circulation are more aggressive in pregnancy. They are drawn to the feto-placental interface where they are activated by different lymphokines and cytokines which can be found in quantity at this site. The role of these local active monocytes is not limited only to phagocytosis because among the hundred substances that they can elaborate are some that will regulate trophoblastic proliferation. The activity of the Natural Killer cells that are circulating and which can control tumour cell growth and cells infected by viruses is lowered in pregnancy. The serum taken from pregnant women seems to have a substance that counters the maturation of the Natural Killer cell lines. The complement system of protein synthesis, which normally acts to lyse bacteria in the chemotaxis during opsonisation, is raised in pregnancy. At the feto-placental interface it does seem to activate this system but not elsewhere in the general circulation. Interferon, which is a molecule that normally activates NK cells, has been found at the feto-placental site, without seeming to have a particular role. Pregnancy changes the quantity and the distribution of other elements in the non specific immune system such as transferrin , fibronectin and beta-lysin.

[The fetal-maternal interface. Description of its elements from an immunologic perspective]. / Interface foeto-maternelle. Description des éléments dans une perspective immunologique.

The authors describe the different elements that can change the immunological response at the feto-maternal interface having studied the increasingly large literature on the subject. They consider first the nature of the interface and how trophoblastic antigens occur and then they point out the type and the role played by the different numerous decidual cells that take part in recognising, activating and regulating the immune system there. This general review is justified because local immunological phenomena seem to be important for the survival and the development of the feto-placental unit. They are also for immuno-suppressant mechanisms and immuno-tropic mechanisms. These phenomena, however important they may be, make it necessary to recognise one or more embryonic or trophoblastic antigens acting on the maternal immunological system.

[Specific immune relationships among the mother, the fetus and the trophoblast. Present-day aspects]. / Les relations immunitaires spécifiques materno-foeto-trophoblastiques. Aspects actuels.

Studying the literature, which is becoming larger and larger, the authors note that there is increasing understanding about the immune response that allows a harmonious development of the feto-placental unit. After the recognition of certain trophoblastic antigens there followed the activation of lymphocytes which synthesize substances favourable to trophoblastic growth. At the same time protective mechanisms which inhibit the generation and activation of immunological factors which are normally found when allografts are rejected, were recognized. Also recognized were other systems able to suppress aggressive features that can become active during pregnancy.

[Immunological aspects of pregnancy]. / Aspects immunologiques de la grossesse. 19H

The authors undertake a review of the literature so that they can point out present knowledge of the immunological relationship between mother and fetus. The fetus is a true allograft since it carries paternal antigens. Total harmony occurs so that immunisation of the mother against the feto-placental unit is recognised. This immunological reaction must occur to allow smooth development of the fetus with, at the same time, protection of the mother against trophoblastic invasion. Many regulatory mechanisms are summoned up to bring about this immunological response. While the progress in immunological knowledge has enabled us to glimpse this immunological relationship, it seems strongly probable that knowledge of these mechanisms can have applications outside gynaecology and obstetrics and be of equal value in the interpretation of immunological reactions which are found on oncology and parasitology.

[Multiple-fetus pregnancies. I. Myths and reality]. / Les grossesses multifoetales. I. Mythes et réalités.

Pregnancies with many fetuses (triplets and more) have at all times been found interesting and unusual. Their rare and spectacular characteristics have for long been considered as divine punishment for the sin of adultery or bestiality or on the other hand as a mark of fertility and a gift from God. The authors report several legends (the Porcelets, the Trazegnies, la Dame de Montigny...) as well as the celebrated cases of fraud. Since techniques have been developed for medical handling of assisted reproduction, multiple pregnancies have become much more frequent. There is no case of survival of all fetuses when there have been more than six born at a time.

[Abortions of immunologic origin. A trial of etiologic classifications and therapeutic consequences]. / Avortements d'origine immunologique. Tentative de classifications étiologiques et conséquences thérapeutiques.

Repeated unintentional abortions are an agonizing problems for many couples. When the cause is unexplained an immunological reason is often invoked. There have been many theories, but none have been able to be proven. Progress in immunology makes it possible to predict that these mechanisms will become better understood. At the present time the most recent work presented by the authors underlines the fact that there are probably several different immunological mechanisms causing abortion. When the mechanisms can be identified using current techniques, it may be possible to suggest the treatment suited to each one of these situations and to abandon empirical treatment as is at present used in these repeated abortions.