Prenatal natural history of congenital pulmonary malformations: MALFPULM population-based cohort study.

OBJECTIVES: To assess prenatal changes in the volume of congenital pulmonary malformations (CPM) and examine whether these changes differ in lesions that appear cystic on ultrasound compared with hyperechoic lesions, and to study the relationship between CPM volume and risk of fetal compression. METHODS: We conducted a nationally representative, multicenter, prospective cohort study, which included 579 ultrasound examinations in 176 pregnant women with a diagnosis of fetal CPM, between March 2015 and November 2016. Several ultrasound examinations were performed between diagnosis and delivery, including measurement of CPM volume. We modeled changes in CPM volume ratio (CVR) as a function of gestational age, overall and for cystic/mixed vs hyperechoic malformations, and examined the association between CVR and signs of compression during pregnancy. RESULTS: When modeling CVR changes over time, there was a statistically significant decrease in CVR with increasing gestational age (P < 0.001), but the pattern of change differed according to CPM phenotype at first ultrasound examination: cystic/mixed CPM were characterized by a monotonic decrease in CVR with increasing gestational age (P = 0.002), whereas hyperechoic CPM showed an initial increase in CVR up to 27 weeks of gestation, followed by a decrease thereafter (P < 0.001). Peak CVR values were predicted as early as 21-22 weeks for cystic/mixed CPMs compared with 25-26 weeks for hyperechoic malformations. Regardless of CPM phenotype, fetuses that showed no sign of compression at any point had substantially lower CVR at first CVR measurement, and the CVR remained relatively constant thereafter. Among the subpopulation of fetuses with no sign of compression at first CVR measurement, the odds of a subsequent compression was 7-fold higher (adjusted odds ratio, 7.0; 95% CI, 1.6-29.9) if initial CVR was > 0.4 vs CVR ≤ 0.4 cm2 . CONCLUSIONS: Predicted changes in CVR during pregnancy differ between cystic and hyperechoic malformations. This may be the result of different pathophysiological mechanisms or differences in the timing of occurrence of these different types of CPM. CVR measured at the initial diagnostic ultrasound examination was strongly associated with the odds of subsequent compression. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

[Hypertensive syndromes in pregnancy. Physiopathology, definition and fetomaternal complications]. / Syndromes hypertensifs de la femme enceinte. Physiopathologie, définitions et complications évolutives materno-foetales.

A MAJOR CONCERN: Hypertensive syndromes occur in approximately 10 to 15% of all pregnancies and are the cause of 30% of maternal deaths and 20% of fetal and neonatal deaths. Syndromes include gestational hypertension also called pregnancy-induced hypertension, chronic hypertension and preeclampsia. DEFINITION: In pregnant women, hypertension is defined as blood pressure levels above 140/90 mmHg at two successive measurements at a 4-hour interval. The primum movens is the development, at about 16 weeks gestation, of secondary placental ischemia due to a defect in the second trophoblastic invasion of the spiral arteries of the myometrium. This induces endothelial dysfunction leading to pro-coagulation activation and inhibited physiological vasodilatation. RISK FACTORS: The risk of vasculoplacental disease increases with age, body mass index, primiparity, stressful working conditions, and personal history of vascular events during pregnancy. MATERNAL RISKS: Maternal complications include preeclampsia-eclampsia, retroplacental hematoma, acute renal failure, and HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count). FETAL RISKS: Hypotrophy, in utero death and prematurity may occur. The development of hypertension during pregnancy may also reveal a hypertensive background which could progress to persistent high blood pressure. Preeclampsia is an independent risk factor of cardiovascular disease requiring regular surveillance after delivery.

[Hypertensive syndromes in pregnancy. Diagnosis and therapy]. / Syndromes hypertensifs de la femme enceinte. Prise en charge diagnostique et thérapeutique.

UNLABELLED: ACHIEVE PRECISE DIAGNOSIS: Hypertensive syndromes during pregnancy secondary to placental ischemia still cause threatening matemofetal complications. A precise differential diagnosis between gestational hypertension, chronic hypertension and preeclampsia must be achieved as the management protocols are quite different. PATIENT MONITORING: Blood tests for urea, creatinine, platelet counts, coagulation, and liver enzymes are required. Fetal monitoring, urine protein and ambulatory blood pressure measurements are also helpful. Ultrasound-Duplex explorations allow an evaluation of the maternal vascular status and fetal development. THERAPEUTIC MANAGEMENT: These patients should be managed in specialized centers, limiting the minimum the number of hospitalizations. Unlike good rules of hygiene and dietetics, antihypertensive therapy has little effect on the progression of the pregnancy. An antihypertensive therapy is only warranted to avoid cardiovascular complications in the mother. In case of chronic hypertension, treatment should be tailored to the measured pressures. Prudent antihypertensive therapy may be useful for severe gestational hypertension and preeclampsia. Because of their safety profile and pharmacologic properties, antihypertension drugs with central action and alph-beta-blockers should be preferred over other drug classes. PREVENTIVE TREATMENT: Antiaggregates (aspirin 50-100 mg/d) starting at 16 weeks gestation should be reserved for high-risk pregnancies. Regular follow-up, both pre- and post-natally, is essential, especially in light of the large number of women who can be expected to progress to established hypertensive states.

[Modifications of heart rate and blood pressure during pregnancy]. / Modifications de la fréquence cardiaque et de la pression artérielle au cours de la grossesse.

The pathophysiology of pre-eclampsia, disease of the endothelium, placental ischaemia, and its consequences on blood pressure and heart rate variations are described. The methods of evaluation of heart rate and blood pressure during pregnancy, outpatient visit clinical measurement, self-measurement, ambulatory measurement, "Finapres", electrocardiogram and Holter ECG are reviewed; the practical implications of the nocturnal fall of vagal tone with tachycardia, demonstrated during pre-eclampsia, are discussed.

Consecutive successful pregnancies in a combined liver and kidney transplant recipient with type 1 primary hyperoxaluria.

Pregnancy is now a common, but high-risk event, in young women who have received transplants. Consequences to the fetus are known, but pregnancy may also interfere with graft function. We report the outcome of two successive and successful pregnancies in a 29-year-old woman with type 1 hyperoxaluria, who received a combined liver and kidney transplant. Two healthy children were born at 35 and 37 weeks of gestation, with low birth weight. Liver function remained normal before, during, and after pregnancies up to 52 months after transplantation. Renal function was impaired before the first conception, worsened during both pregnancies, and returned to the previous level in both immediate postpartum periods. However, renal function has declined 17 months after the last delivery. This report shows the feasibility of successive pregnancies in multiple organ transplant recipients, but raises the question of long-term maternal kidney graft survival.

[Pregnancy after hepatic transplantation: what is the maternal risk?]. / Grossesse après transplantation hépatique: quel est le risque maternel?

OBJECTIVES AND METHODS: We report 7 pregnancies which occurred from 1988 to 1995 in 5 women who underwent liver transplantation. The immunosuppression regimen associated cyclosporine, azathioprine and prednisone. RESULTS: Mean age at conception was 25. During pregnancy, cholestasis occurred in 2 women. None of the patients experienced rejection. An increase in serum creatinine was observed in 3 cases. Serum uric acid increased in the third trimester of pregnancy in 6 cases, associated with arterial hypertension in 3 cases. In 4 cases, toxemia led to premature delivery. Seven childbirths occurred between the 34th and 38th week of gestation, by vaginal delivery (n = 3) or caesarean section (n = 4). Newborn weights ranged from 1,350 g to 3,100 g. A favorable outcome was observed in all mothers, with a follow-up ranging from 2 months to 7 years after delivery. CONCLUSION: These results suggest that a successful pregnancy is possible after liver transplantation in young women with normal hepatic function and treated with cyclosporine. The risk of toxemia is mainly related to renal function before pregnancy.

Prenatal diagnosis of metatropic dwarfism.

We present a case of prenatal diagnosis of severe metatropic dysplasia at 20 weeks' gestation. The characteristic prenatal features of this rare autosomal recessive chondrodysplasia appear to be significant dwarfism with an enlarged head and a narrow thorax associated with enlargement of the hands and feet, and the radiographic 'dumb-bell' appearance of the long bones.

[Evaluation and surveillance of blood pressure during pregnancy]. / Evaluation et surveillance de la pression artérielle au cours de la grossesse.

Despite a large body of literature or hypertension in pregnancy, there still is no recognized prognosis factor for this frequent and severe disease. Management still relies on clinical features (occasional blood pressure measurements, weight curve) and appropriate tests including fetal and maternal echodoppler, urinary uric acid, 24 h proteinuria and fetal heart rate monitoring. Recent developments including self measurement and ambulatory monitoring of blood pressure have helped improve follow-up and therapeutic management in high risk pregnancies. By repeating the measurements, these techniques require more intensive medical follow-up and an adapted therapy near the term of pregnancy. They do not however provide a means of predicting outcome or recurrence of preeclampsia. These techniques have effectively been shown to reduce the number and duration of hospitalizations.

[Ambulatory arterial blood pressure monitoring in the management of hypertension in pregnancy]. / Apport du monitoring ambulatoire de pression artérielle dans la prise en charge de l'HTA gravidique.

Ambulatory blood pressure monitoring (ABPM) completes the diagnostic approach to hypertension of pregnancy, by providing a dynamic study of the blood pressure status of the pregnant woman. It corrects certain erroneous diagnoses of hypertension of pregnancy, in particular those related to the "White coat" effect, especially common in pregnant women. ABPM enables the study of nocturnal blood pressured figures, known for their prognostic value in hypertension of pregnancy. Finally, while loss or reversal of circadian rhythm appears to be of good predictive value regarding the onset of eclampsia, it is above all blood pressure load which appears to be harmful to fetal growth and maturity. ABPM also facilitates management by improving the compliance of pregnant women with regular monitoring and with treatment, by more accurately guiding the surveillance of drug treatment.

[Obstetrical anesthesia of patients with disseminated lupus erythematosus]. / Anesthésie obstétricale des patientes atteintes de lupus érythémateux disséminé.

The anaesthetic management of pregnant women who suffered from systemic lupus erythematosus (SLE) was reviewed retrospectively. During the ten-year period studied, there were nineteen pregnancies in eighteen women (mean age 27 years) who had either SLE or an isolated lupus type anticoagulant (LAF). Four pregnancies were stopped before the third trimester, two spontaneously, and the other two because of the mother's condition. Of the fifteen remaining pregnancies, eight children were born with a weight less than 2,500 g. One child, birth weight 750 g, died after three days. None of the fourteen living children had neonatal lupus. Six epidural and twelve general anaesthetics were carried out for four abortions, nine Caesarian sections, and five deliveries. Epidural anaesthesia was often contraindicated by neurological and haemostatic complications of the SLE: recent meningitis, thrombocytopaenia, prolonged bleeding, anticoagulant therapy. In fact, management of SLE patients required extensive preanaesthetic clinical and paraclinical assessment, as all the systems may be involved in this condition; moreover, it may worsen during pregnancy (seven times in this series). The most frequent complications were cardiovascular, renal, and haematological. Possible intubation difficulties must also be looked for. A LAF was associated with a great number of venous thromboses. An isolated LAF does not contraindicate epidural anaesthesia, as long as there is no associated haemostatic defect, such as a thrombocytopaenia. Furthermore, the patient should not have had prolonged episodes of unexplained bleeding, or require anticoagulants. In the present series, epidural anaesthesia was contraindicated in three of the four patients with LAF. Finally, prevention of thromboembolism, postoperative infection and adrenal failure (in those patients with long-term steroid therapy) must be carried out.