[Contribution of volume ultrasound in the evaluation and prenatal care of fetal cardiovascular anomalies]. / Apport de l'échographie volumique dans l'évaluation et la prise en charge prénatale anténatale des anomalies cardiovasculaires fœtales.

OBJECTIVES: To highlight the value of 3D ultrasound in the prenatal assessment of fetal cardiovascular abnormalities. PATIENTS AND METHODS: A retrospective offline analysis of volume datasets of fetuses diagnosed with cardiovascular anomalies by 2D ultrasound was performed. RESULTS: Thirty-four fetuses with 38 cardiac malformations were evaluated. Mean gestational age at diagnosis was 26 weeks. Isolated cardiovascular malformations were detected in 23 fetuses. Extracardiac abnormalities were identified in eight fetuses. Ten terminations of pregnancy were performed. CONCLUSION: Offline analysis of cardiovascular anomalies conferred significant diagnostic advantages over 2D ultrasound. 3D ultrasound is a valuable tool for the prenatal diagnosis and the management of congenital heart diseases.

[Subsequent pregnancy outcomes after first pregnancy with severe preeclampsia and delivery before 34 weeks of gestation]. / Avenir obstétrical après une première grossesse compliquée d'une prééclampsie sévère avec accouchement avant 34 SA.

OBJECTIVES: Women who had severe preeclampsia are at high risk of gestational vascular complications (preeclampsia, gestational hypertension, fetal death, small for gestational age, placenta abruptio) in subsequent pregnancies. The aim of this study was to describe outcomes of subsequent pregnancy after severe preeclampsia with delivery before 34 weeks of gestation during the first pregnancy. PATIENTS AND METHODS: One hundred and thirty-four primiparous women delivered before 34 weeks of gestation resulting in severe preeclampsia between January 2002 and December 2009. The data of the index pregnancy were identified from the medical record of our maternity, those of the subsequent pregnancy from paper or computerized medical records of the hospitals where deliveries took place. Our study ended on December 31 2011 for a decrease of at least 2 years after the index pregnancy. RESULTS: Of the 75 subsequent pregnancies, 59 have been studied. Twenty patients (34%) had gestational vascular complications, in type of gestational hypertension alone (10%), preeclampsia (65%), isolated small for gestational age (20%) or fetal death (5%). Thirty-nine patients (66%) showed no recurrence of gestational vascular complications but only 33 patients (56%) had a pregnancy of course totally physiological. The only risk factor for recurrent gestational vascular complications in subsequent pregnancy was a long time interval between two pregnancies, with an increased risk in case of delay beyond 26 months. CONCLUSION: Women with a history of severe preeclampsia with delivery before 34 weeks of gestation during first pregnancy are at increased risk for gestational vascular complications during the next pregnancy. A close obstetrical monitoring is recommended during a subsequent pregnancy.

[Contribution of 3D-ultrasound in the heterotaxy syndromes: about four cases and review of the literature]. / L'apport de l'échographie 3D dans les syndromes d'hétérotaxie : à propos de quatre cas et revue de la littérature.

The position or location of the organs and vessels is usually classified into three types: situs solitus, situs inversus, and situs ambigus. Situs solitus is the usual arrangement of organs and vessels within the body. Only 0.6 to 0.8% of patients with situs solitus and levocardia have associated congenital heart diseases. Situs inversus refers to an anatomic arrangement that is the mirror image of situs solitus. The incidence of congenital heart disease is increased to 3 to 5% in the patients with situs inversus. The patients with heterotaxy have congenital heart disease in high incidence, ranging from 50 to nearly 100%. We present four cases diagnosed in our department in a period of 18 months. With these four cases and a review in the literature, we explore the definitions and characteristics of heterotaxy syndromes and we study the role of 3D ultrasound.

[Acute pulmonary edema and pregnancy: a descriptive study of 15 cases and review of the literature]. / Œdème aigu du poumon et grossesse : étude descriptive de 15 cas et revue de la littérature.

OBJECTIVE: To describe the incidence and the etiologies of acute pulmonary edema (APE) and the diagnostic procedure used during pregnancy and immediate post-partum. MATERIALS AND METHODS: We analyzed records from a search of codes of heart failure and APE as well as from the term "pulmonary edema" in computerized obstetric records from 2002 to 2010 in a university center of level 3. We identified maternal characteristics, the term of appearance and route of delivery, the time between symptoms and diagnosis, additional tests performed, and data from echocardiography. RESULTS: Fifteen patients had an APE during pregnancy or in the immediate post-partum period during the study period (0.05%). The mean age was 28.6 years and the mean term of appearance was 31.2±3.1 weeks of amenorrhea. The diagnosis was made in 11 cases (73.3%) before delivery and in four during post-partum. The main etiology was preeclampsia (46.6%) followed by heart disease (26.7%), then tocolysis and overfilling (13.3%). In 55% of cases, we found a diagnostic wander characterized by carrying out further unnecessary tests. The echocardiography has led to a change in management in 27.3% of cases. CONCLUSION: The APE is a rare event during pregnancy and the post-partum period and its main etiology is preeclampsia. Some other etiologies are avoidable like the use of beta-agonists by intravenous route. The diagnosis is sometimes difficult, but the realization of a chest X-ray, a simple and inexpensive test, is enough to confirm it.

[From the impact of French guidelines to reduce episiotomy's rate]. / De l'impact des RPC pour réduire le taux d'épisiotomie.

OBJECTIVES: Following the publication of the French Guidelines on episiotomy in 2005 by the French National College of Gynaecologists and Obstetricians (CNGOF), our unit decided to adopt a restrictive politics to replace the former liberal one. The goal of this study was to evaluate the impact of this modification of trend in the Unit of Gynaecology and Obstetrics of the teaching hospital from Caen. This was the start point of an internal audit with the objective of an enhancement of the care during delivery. PATIENTS AND METHODS: It was a retrospective study concerning the period going from January, 2004 till December, 2009, measuring the impact of the guidelines on the episiotomy rates and perineal tears. The totality of the population of the women naturally delivered at a term superior or equal to 37 weeks of gestation and a cephalic presentation was included. To modify the practices, after diffusion of the guidelines by some obstetrical leaders, we imposed to notify the indication of the episiotomy in the computerized obstetrical files. Moreover, we published monthly screenboards with all the detailed results to all the practioners acting in the delivery room (obstetricians, midwives). RESULTS: Between 2004 and 2009, we observed a dramatic decline of the episiotomy rates from 55.7 to 13.3%. This trend was the same for primiparae and multiparae, as wall as for spontaneous or assisted delivery (mostly vacuum extraction in our unit). We noticed a slight increased in minor perineal tears without functional consequences. There was no statistically significant difference between severe perineal tear (1.3% vs. 1.1%). By contrary, the rate of intact perineum significantly raised (17.6% vs. 21.7%, p<0.001), especially in vacuum extractions. DISCUSSION: Our results are in accordance with those of the national guidelines. However, our rate does not decrease in 2007 and 2008 (20%), contrary to some results obtained in the literature. Some reports mentioned the weak impact of the publication of national guidelines to modify the usual practice. However, we believe that retro-information to practitioners has a real impact on their daily current practice. Hence we insisted again on the importance of these national guidelines at the end of 2008 and we could demonstrate a real decline of the rate of episiotomy. Our efforts have to be continued, especially for instrumental delivery.

[History of pubic symphysis separation and mode of delivery]. / Antécédent de disjonction pubienne et modalités d'accouchement.

Pubic symphysis separation is an underestimated and badly treated pathology. It can be responsible for an important morbidity and therefore requires a fast and specialized management. In case of subsequent pregnancy, mode of delivery will have to be discussed due to traumatic past and maternal fear of recurrence. After two cases of patients who experienced preventive cesarean delivery after symphyseal separation in a prior pregnancy, a retrospective study reporting pubic disjunction cases during the last 10 years in our unit was made. Few data are available in the literature and risks of recurrence are not well-defined. Vaginal delivery may be proposed, leaving a wide place to discussion with the patient, evoking prevention and therapeutic possibilities.

[Lymphocytic choriomeningitis virus and fetal anomalies]. / Infection par le virus de la chorioméningite lymphocytaire et fœtopathies.

OBJECTIVE: Lymphocytic choriomeningitis virus (LCMV), a rodent-borne arenavirus, is an uncommonly recognized cause of severe congenital viral infection. The incidence of this infection during pregnancy is still unknown. Our study aimed to evaluate LCMV infection frequency in pregnancy with fetal neurological abnormalities of unknown etiology. MATERIAL AND METHODS: Samples obtained during three years from 160 pregnant women were retrospectively analysed: 155 maternal sera, 150 amniotic fluids (AF) and 12 fetal sera (FS). Congenital neurological anomalies were diagnosed but TORCH and culture investigations were negatives. Serological analysis was performed with L929 cells infected with the Armstrong strain of LCMV. IgG and IgM antibodies against CMLV were researched by immunofluorescence assay using these infected cells. Interferon alpha was also assayed for AF and FS. RESULTS: No positive serology was found in any of the 317 samples investigated even when interferon alpha was detected. CONCLUSION: This result confirms the rarity of LCMV infection in France. Nevertheless, at the light of the recent literature, this teratogenic pathogen should be considered in pregnancy with unexplained congenital malformation, especially after rodent exposure.

[Prevention of early-onset group B Streptococcus infections. 2. Efficiency of the ANAES guidelines]. / Prévention des infections maternof0etales à streptocoque B. 2. Efficacité des recommandations de l'Anaes.

OBJECTIVES: To examine the efficiency on early-onset neonatal infections of the ANAES guidelines for early-onset infections prophylaxis, based on a systematic prenatal vaginal swab aiming Group B Streptococcus and/or infection risk factors during delivery. PATIENTS AND METHODS: This is a retrospective cohort study of early-onset infections during a period of 28 months (6125 deliveries) compared to an earlier period (6141 deliveries). RESULTS: The number of newborns admitted for suspected infection and the rate of sepsis have been unchanged. But the total number of infections has decreased (1.50 vs 2.02 %, p=0,024), without increase of the number of infections due to other germs such as Escherichia coli. Furthermore, a strategy based only on risk factors would not have allowed the early screening and treatment of 23 Streptococcus B infected newborns. CONCLUSION: We have proved the efficiency of the protocol in terms of prevention of early-onset infections. However, it has led to a dramatic increase in the consumption of antibiotics, which is worrying concerning maternal and neonatal bacterial ecology.

[Prevention of early-onset group B Streptococcus infections. 1. Application of the ANAES guidelines]. / Prévention des infections maternofœtales à streptocoque B. 1. Application des recommandations de l'Anaes.

OBJECTIVES: To examine adherence to the Anaes guidelines for early-onset infections prophylaxis, based on a systematic prenatal vaginal swab aiming group B Streptococcus and/or infection risk factors during delivery. PATIENTS AND METHODS: Retrospective study of 6125 consecutive deliveries through a 28-month period. Data were collected from the patients files recorded in a computer database. RESULTS: Overall, a vaginal swab was performed on 88.3% of the patients. Among these, 79.1% were performed according to the guidelines. Among the patients, 90.2% with a positive swab received intrapartum antibiotics. In accordance to the national guidelines, we noticed a 40% increase in the consumption of antibiotics, without any severe complication during the study. Certain points must be improved though: time of the sampling, antibiotic therapy in case of quick delivery, management of patients with allergy to penicillin. CONCLUSION: Concordance with the national guidelines is feasible in a department with a high obstetrical activity.

[Diagnosis of chorionicity]. / Le diagnostic de chorionicité

INTRODUCTION: The recognition of mono- and dichorionic twins is highly important and should be performed as early as possible during the pregnancy. This is justified by major differences between these two types of pregnancies for fetal mortality, morbidity, features of the complications, and appropriate follow up is required. OBJECTIVES: To determine the modalities for the diagnosis of chorionicity. METHODS: Articles were searched using PubMed, Embase and Cochrane library. RESULTS: The diagnosis of chorionicity is appropriately made by the ultrasound examination. Before 10 weeks of gestation, the appearance and count of the gestational sacs is the best method (ELNP2). During first trimester ultrasound examination at around 12 weeks of gestation, the lambda sign is the most relevant sonographic sign (ELNP2). The diagnosis of chorionicity should be mentioned in the report of the first trimester scan. The diagnosis of chorionicity performed at first trimester is the reference for the rest of the pregnancy. Indeed, further determination of the chorionicity at second or third trimester is less accurate and more difficult. It should be performed by a combination of sonographic signs (fetal sex, twin peak sign, location of the placenta(s), or counting the layers of the amniotic membrane) (ELNP2). When the diagnosis of chorionicity cannot be obtained, the patient should be offered a second scan in a reference center (expert opinion). CONCLUSIONS: The knowledge of the chorionicity is necessary for appropriate follow up of twin pregnancies. Ultrasound examination is a reliable method for the diagnosis of chorionicity early during the gestation.

[Elective single embryo transfer - the Scandinavian experiment]. / Transfert électif d'un embryon - le modèle scandinave.

Limiting the number of embryos transferred from three to two does not reduce the high risk of twin pregnancy (between 21 and 40%). Scandinavian centers have proposed in the 2000s the elective single embryo transfer (eSET) as the only means to reduce maternal, neonatal and psychological consequences related to multiple births. Pooled results from prospective randomized controlled trials and prospective cohort studies comparing eSET and transfer of two embryos (DET) in a selected population have confirmed the almost complete disappearance of twins when eSET was effective but the compromising effect of eSET upon live birth rates was discussed. Optimizing the eSET overall pregnancy rate need to associate a freezing policy and to define risk factors for increased chance of multiple birth (patient age, diagnosis, number of top-embryos or unsuccessful attempts). The extension of eSET practice to an unselected population irrespective of embryo quality is still controversial. The choice between offering one cycle of SET or DET in an unselected patient population depends on the society's willingness to optimize the in vitro fertilization results according to a defined health care policy: the first one is the twins disappearance with reduced overall pregnancy rate and the second one is a reduced twin birth rate with maintain of the total pregnancy percentage. The real question is to define what percentage of twin pregnancy could be considered as acceptable.

[Fetal pulse oximetry: clinical practice]. / Oxymétrie de pouls foetal en pratique clinique.

OBJECTIVE: To assess in current practice the application of our protocol of using fetal pulse oximetry during labor, to evaluate whether fetal scalp blood sampling can be reduced and to determinate reliability of fetal pulse oximetry on the prediction of poor neonatal outcomes. STUDY DESIGN: Prospective observational unicenter cohort including 449 patients during two years. All pregnancies were singleton, greater than or equal to 37 weeks' gestation, cephalic presentation, and had non reassuring fetal heart rate. The poor neonatal outcome was defined by one of the followings: arterial umbilical cord pH

Antenatal sonographic features of aneurysmal dilatation of a vitelline vein.

We report a case of aneurysmal dilatation of a vitelline vein observed antenatally. Intra-abdominal vascular dilatation was diagnosed on ultrasound examination at 24 weeks' gestation. The relationship with the umbilicus and portal vein suggested the diagnosis of umbilical vein varix. Fetal tolerance remained excellent in spite of a gradual increase in the size of the dilated vein. Postnatal ultrasound examination revealed thrombosis of the aneurysm with gradual extension to the portal vein and the onset of serious coagulation problems. Operative findings on postnatal day 9 included the absence of intra-abdominal umbilical vein, and the presence of an abnormal, dilated and thrombosed vein connecting the umbilicus to the portal vein and following the trajectory of the right vitelline vein. Corrective surgery was attempted by resection of the aneurysm and portal thrombectomy, but this did not prevent the development of portal obstruction syndrome with cavernous hemangioma. This anomaly, in which the fetal venous return uses the vitelline vein in the absence of the umbilical vein, does not appear to have been described before. The mechanism in question could be anastomosis between the right vitelline vein and umbilical vein. Antenatal diagnosis should enable early surgical management before the formation of a portal thrombosis.

Rupture of the scarred uterus.

OBJECTIVE: To assess the risk of uterine rupture of the scarred uterus according to mode of delivery in subsequent births recorded as spontaneous labour, labour induced by oxytocin, labour after ripening with prostaglandin E2, and planned cesarean section. METHODS: Retrospective study of 2,128 births with a low transversal scar after a previous cesarean section. The study population was realised in a level III university hospital from 1995 to 2003. The association between mode of delivery and uterine rupture was studied in a multivariate logistic regression model, and adjusted for specific antenatal confounding factors. RESULTS: Over 9 years, we collected 22 cases (1%), including 11 asymptomatic ruptures in a population of 2,128 scarred uteri out of 28,248 deliveries. Uterine rupture occurred at a rate of 0.3 per 100 among women with repeated cesarean delivery without labour, 1 per 100 among women with spontaneous onset of labour, 1.4 per 100 among women with oxytocin-induced labour, and 2.2 per 100 among women with prostaglandin cervical ripening. Compared to women with a planned cesarean section, women with spontaneous onset of labour were more likely to have uterine rupture (OR: 4.0; 95% CI: 0.8-42.0). A greater relative risk was observed among women with oxytocin-induced labour (OR: 4.3; 95% CI: 0.3-60.0), and particularly those with prostaglandin-induced labour (OR: 8.7; 95% CI: 1.5-97.3, p=0.01). CONCLUSION: In women with a scarred uterus, prostaglandin E2 induction of labour is a risk factor for uterine rupture. The practice of a systematic cesarean section in cases with Bishop score<3, appropriate induction procedure, and rigorous monitoring of the labour, could make for a safer delivery.

[Uterine and ovarian necrosis following embolisation of the uterine arteries for postpartum haemorrhagia]. / Nécrose utérine et ovarienne après embolisation des artères utérines pour hémorragie de la délivrance.

We report here the case of a young woman who presented with pain, fever and apparent cutaneous sub ischaemia following embolisation of the uterine arteries for postpartum haemorrhagia. This embolisation was carried out by bilateral selective catheterism of the uterine arteries using 45 to 150 micron polyvinyl alcohol particles. Investigative laparotomy was decided in view of the persistence of the symptoms, and the patient underwent hysterectomy with ablation of the right adnexa to treat uterine necrosis and adnexal atrophy. Because of the information that we have actually, we can explain that this complication is linked with the use of polyvinyl alcohol small size particles. The migration of those embolisation agents might be responsible for obliteration of a large number of distal vessels. Those embolisation agents must, because of recommendation for good practice published in 2004, be reserved to exceptional cases to minimize the complication of embolisation.

[A rare complication of vomiting in pregnancy: Wernicke's encephalopathy]. / Une complication rare des vomissements gravidiques: l'encéphalopathie de Gayet-Wernicke.

Gayet-Wernicke syndrome is a rare neurological pathology due to a deficit in vitamin B1. It occurs in alcoholics but several reports have been published of cases in a context of intractable vomiting. The frequency is probably under-estimated because there have been many cases described at autopsy. The diagnosis is clinical with the triad (found in 60% of cases) of mental confusion, oculomotor disorders and ataxia. MRI can confirm the diagnosis by hyper signal images most frequently in a peri-acqueductal location, the thalamus and mamillary bodies. We report 3 observations of Gayet-Wernicke encephalopathy discovered in a context of hyperemesis gravidarum. These 3 cases, which occurred within the past two years in the West of France, give us the opportunity to assess 3 different outcomes for this pathology. In a second section we review the main publications in the literature. Hyperemesis gravidarum is a frequent pathology and can be the cause of serious neurological complications. Early vitamin supplementation should be instituted in case of severe vomiting in order to ensure the pregnancy can continue together with the mother's well-being.

[Laparoscopic management of pelvic mass in pregnancy]. / Prise en charge coelioscopique des masses latéro-utérines pendant la grossesse.

OBJECTIVES: To determine the feasibility, safety and limiting factors of laparoscopic management of pelvic mass in pregnancy. MATERIAL: and methods. During a 10-year period, 21 laparoscopic procedures were performed in patients with pelvic masses in pregnancy after exclusion of appendicitis and ectopic pregnancy. Laparoscopic surgery was done during the first trimester of pregnancy in 8 cases, the second trimester in 12 cases and the third trimester in one case. All the procedures were performed with general anesthesia and the laparoscopic cystectomies were performed with the intraperitoneal technique. RESULTS: The indications were: persistent or sonographically abnormal ovarian cyst (12 cases), torsion of ovarian cyst (5 cases), and symptomatic pelvic mass (4 cases: 2 painful cysts and 2 infarction of fibroma). One borderline tumor were discovered. The laparoscopic procedure could not be performed in two cases due to difficulty of access to the lesion. No patient encountered complications during the intra- and post-operative periods. The mean hospital stay was 4.5 days. The outcome of the pregnancy was normal in all cases. CONCLUSION: Laparoscopic management of pelvic masses in pregnancy by an experienced team, is a safe and effective procedure.

[Comparison of women's alcohol consumption before and during pregnancy. A prospective series of 150 women]. / Comparaison de la consommation d'alcool avant et pendant la grossesse: á partir d'une série prospective de 150 femmes.

OBJECTIVES: Evaluation of the prevalence of prenatal alcohol exposure in relation with declared alcohol consumption (DAC). MATERIALS AND METHODS: Observational prospective study based on the DAC of 150 women in post-partum or hospitalized for abnormal pregnancies. The main selection criterion was change in DAC before and during pregnancy, classified according to alcohol use and misuse limits. Excessive alcohol intake was defined as more than 4 glasses on occasion and/or more than 14 glasses a week. Age and professional position were also taken into account. Data were obtained using semi-directive interviews. RESULTS: 79% of these women drank before pregnancy. 33.2% of them had excessive intake. Consumption of more than 14 glasses a week concerned 10% of the population. Excessive consumptions on occasion significantly affected 33% of the population. During pregnancy, 43% of these women continued drinking. Overall excessive intake, which is noxious for children, concerned 9.9% of the women. 5% declared a regular misuse above 14 glasses a week and 7% of them consumed more than 4 glasses on occasion. The average age was 29.8 years. Most of the women (61%) had a stable job. CONCLUSION: Our study confirms alcohol consumption by women, even during pregnancy. Consumptions of pregnant women is decreasing progressively. DAC is very useful to evaluate alcohol intake.

[Antenatal diagnosis and management of vein of Galen aneurysm: review illustrated by a case report]. / Diagnostic anténatal et prise en charge d'un anévrysme de la veine de Galien: revue de la littérature illustrée par une observation personnelle.

Vein of Galen aneurysm is a rare vascular congenital malformation. We report an antenatal diagnosis with duplex Doppler at 26 weeks gestation. Magnetic resonance imaging was used before and after delivery in order to determine neurological prognosis. The neonatal prognosis is poor if fetal cardiac insufficiency or cerebral lesions are present antenatally. Premature delivery does not improve the neonatal outcome. When the aneurysm is not life threatening, embolization of the malformation is at best delayed five months after birth.