Is vaginal delivery of a fetus in breech presentation at an extremely preterm gestational age associated with an increased risk of neonatal death? A comparative study.

BACKGROUND: The effect on neonatal mortality of mode of delivery of a fetus in breech presentation at an extremely preterm gestational age remains controversial. OBJECTIVE: To compare mortality associated with planned vaginal delivery (PVD) of fetuses in breech presentation with that of fetuses in breech presentation with a planned cesarean delivery (PCD). MATERIAL AND METHODS: Retrospective study reviewing records over a 19-year period in a level 3 university referral center of singleton infants born between 25+0 and 27+6 weeks of gestation, alive on arrival in the delivery room, and weighing at least 500 grams at birth. Infants in the first group were in breech presentation with PVD and the second in breech presentation with PCD. The principal endpoint was neonatal death. RESULTS: During the study period, we observed 113 breech presentations with PVD, and 80 breech presentations with PCD. Although not significant after adjustment, neonatal mortality in the breech PVD group was more than twice that of the breech PCD group (19.5 vs 7.8%, P = 0.031, ORa = 2.6, 95% CI 0.8-9.3, NNT = 8). This higher neonatal mortality in the breech PVD group was exclusively associated with a higher risk of death in the delivery room (12.4 vs 0.0% P = 0.001, OR not calculable, NNT = 8). In these extremely preterm breech presentations with PVD, neonatal mortality in the delivery room was associated with entrapment of the aftercoming head, cord prolapse, and a short duration of labor. CONCLUSION: For deliveries between 25+0 and 27+6 weeks' gestation, vaginal delivery in breech presentation is associated with a higher risk of death in the delivery room.

Type of breech presentation and prognosis for delivery.

BACKGROUND: Although its role in the prognosis for delivery remains controversial, the type of breech is sometimes taken into account in the decision about mode of delivery. Objective of our study was to compare maternal and neonatal morbidity for trial of vaginal delivery according to the type of breech (complete or frank). MATERIAL AND METHOD: Single-center retrospective study of women with trials of vaginal delivery of a singleton fetus in breech presentation at of after 37 weeks of gestation. Neonatal status was assessed by the composite variable of the Term Breech Trial, first considered alone, and then with the addition of a 5-min Apgar score < 7 or a neonatal arterial pH<7.0. RESULTS: Of the 495 trials of vaginal delivery during the study period, approximately one third of them were complete breech (35.8 %) and two thirds frank (64.2 %). The frequency of cesareans during labor was similar regardless of the type of breech (16.4 for complete vs 12.6 % for frank, p=0.24), nor did neonatal morbidity differ (1.7 for complete vs 4.1 % for frank, p=0.15). On the other hand, cord prolapse occurred almost exclusively in complete breech presentations (4.5 vs 0.3 %, p<0.01), and prognosis was good in all cases. Complete breech presentations were also associated with more frequent use of forceps to the after-coming head (16.2 vs 9.7 %, p<0.05). Finally, there were non significant difference between the two types of breech concerning severe acidosis but it seemed to have it more in frank breech (2.3 vs 1.2 %, p=0.34). CONCLUSION: Among women eligible for vaginal delivery, the type of breech presentation (complete or frank) has little influence on delivery maternal and neonatal morbidity. The type of breech need not be taken into account in deciding the route of delivery.

Are pregnancies with lupus but without APS of good prognosis?

BACKGROUND: Pregnancies in women with systemic lupus erythematosus (SLE) are at risk of unfavorable perinatal outcomes, especially when antiphospholipid antibody syndrome (APS) is present. Their prognosis is less clear in other situations. OBJECTIVES: To assess pregnancy prognosis in women with SLE but not APS compared with a control series and determine the poor prognostic factors, if any, detectable before 15 weeks' gestation. MATERIAL AND METHODS: This retrospective case-control study included 137 women with SLE, including 114 without APS, and 274 control women. Unfavorable perinatal outcome was defined by perinatal death (≥ 22 weeks of gestation) or preterm delivery ≤35 weeks. RESULTS: Pregnancies of the 114 women with SLE but not APS were at more than twice the risk of unfavorable perinatal outcomes compared with those in the control group (18/114 (15.8%) vs 21/274 (7.7%), OR 2.3, 95% 1.1-4.7). After logistic regression, three factors detectable before 15 weeks were associated with an unfavorable perinatal outcome: i. proteinuria and/or hypertension (in 19.3% of the pregnancies) ii. lack of cutaneous lupus (26.3%), and iii. a history of thrombocytopenia-leukopenia-anemia (19.3%). When these factors were absent, the risk of a poor perinatal outcome was very low (3.3%) but increased strongly for pregnancies with one (22.2%) or at least two (44.4%) of these factors. CONCLUSION: Among women with SLE but not APS in the first trimester, only the presence of risk factors increases the likelihood of an unfavorable perinatal outcome. PRECIS: Pregnancies with SLE but not APS are at risk of unfavorable perinatal outcomes only if risk factors are present.

Special considerations in pregnant systemic sclerosis patients.

INTRODUCTION: Evaluating the fertility and pregnancy outcomes in systemic sclerosis (SSc) women is challenging. Studies are still limited or subject to potential methodological biases. Areas covered: This work is a comprehensive review of the literature. We discuss the potential impact of SSc on women's pregnancy outcomes and the effects of pregnancy on SSc. We summarize the physiological changes during pregnancy and describe our experience. Expert commentary: Although the miscarriage rate does not appear increased in SSc, women are exposed to a higher risk of premature birth and intrauterine growth restriction compared with the general population. Early diffuse cutaneous SSc and use of corticosteroids are risk factors, whereas folic acid use prevents against premature birth. All SSc women wishing to conceive should be counselled during a preconception visit. Physiological changes arising during pregnancy may be the source of clinical problems in SSc women with organs with limited capacities.

[Anterior dislocation of a Incarcerated Retroverted Uterus at 21 weeks of amenorrhea : Case Report. ]. / Luxation antérieure d'un utérus rétroversé incarcéré à 21 semaines d'aménorrhée : à propos d'un cas.

BACKGROUND: An incarcerated uterus refers to the retroversion of a pregnant uterus within the pelvis due to the absence of a forward tilt at the end of the first trimester. An incarcerated uterus that is overlooked or only discovered perpartum can cause severe obstetrical complications. Several authors have shared their experience with uterine incarceration management at 12, 14, and 16 weeks of amenorrhea. CASE: Our report concerns a case of uterine incarceration management at 21 weeks of amenorrhea, achieved by way of a specific anesthesia protocol and the positioning of the patient, which allowed the disimpaction of the uterus with the help of external maneuvers. No recurrence was observed. CONCLUSION: Uterine incarceration management is possible beyond 16 weeks of amenorrhea.

Background: An incarcerated uterus refers to the retroversion of a pregnant uterus within the pelvis due to the absence of a forward tilt at the end of the first trimester. An incarcerated uterus that is overlooked or only discovered perpartum can cause severe obstetrical complications. Several authors have shared their experience with uterine incarceration management at 12, 14, and 16 weeks of amenorrhea. Case: Our report concerns a case of uterine incarceration management at 21 weeks of amenorrhea, achieved by way of a specific anesthesia protocol and the positioning of the patient, which allowed the disimpaction of the uterus with the help of external maneuvers. No recurrence was observed. Conclusion: Uterine incarceration management is possible beyond 16 weeks of amenorrhea.

[Cord blood collection for potential stem cell transplantation to a family member: the long-term experience of a level-III maternity unit]. / Recueil de sang placentaire en vue d'une greffe intrafamiliale de cellules souches: l'expérience continue d'une maternité de niveau III.

BACKGROUND: Cord blood transplantation is used to treat patients with malignant and nonmalignant hematopoietic diseases. This study assessed the feasibility of collecting cord blood for eventual transplantation to a sibling with such a disease. METHODS: We studied the records of 47 infants from whom cord blood was collected for siblings from 1993 through 1999. RESULTS: During the study, cord blood was collected for 47 potential recipients: 37 (80.4%) with malignant disease and 9 (19.6%) with nonmalignant disease. Delivery was induced before 39 weeks of gestation. The mean volume collected was 107+/-39 mL and the number of nucleated cells was 11.52 x 10(8). Problems making collection difficult included: impossibility of collecting cord blood because of spontaneous delivery (n=1), the cytomegalovirus-positive serologic status of donor (n=7), and an inadequate number of nucleated cells (n=16). Weekday collection was possible for 60% of the donors. To date, only 7 of these cord blood collections have been used for stem cell transplantations. CONCLUSION: This retrospective study demonstrates the practical difficulties in collecting cord blood for transplantation to siblings, difficulties that may decrease the likelihood of success.

[Indications and monitoring of antithrombotic prophylaxis for venous thromboembolism during pregnancy and post-partum]. / Indications et surveillance du traitement prophylactique de la maladie thrombo-embolique veineuse au cours de la grossesse et du post-partum.

Pregnancy and puerperium are well-known risk factors for venous thromboembolism, but the actual incidence of the disease is low (about 1/1,500 pregnancies). Pregnancy-associated venous thromboembolism is rare, though it is still the second cause of maternal death in France. Several types of prophylaxis are available, mainly clinical vigilance and aggressive investigation of women with symptoms of venous thromboembolism, or antithrombotic prophylaxis. Given the low incidence of the pathology, it seems desirable to select high-risk groups of women for such strategies. The most studied and identified risk factors are prior episodes of venous thromboembolism and biological thrombophilias. Prophylaxis through low molecular weight heparin during pregnancy and the puerperium should be considered mainly in these two groups. Noteworthy, no prospective and randomized study is available, and treatment recommendations are grade C.