Effects of selective reduction in triplet gestation: a comparative study of 80 cases managed with or without this procedure.

OBJECTIVE: To evaluate the effect of selective termination in triplet pregnancies. DESIGN: Comparative, prospective, nonrandomized study. SETTING: All 80 pregnancies were managed in a single tertiary center by the same obstetrical team. PATIENTS: Eighty women with triplet pregnancies were divided into two groups: group I consisted of 48 women who wished to continue their pregnancies without reduction; in group II were 32 women who choose reduction generally to obtain twins. INTERVENTIONS: Selective terminations were performed after an average term of 9.6 weeks of gestation by transcervical or transabdominal approaches. MAIN OUTCOME MEASUREMENTS: The rate of miscarriage and prematurity, fetal growth, perinatal morbidity and mortality, and maternal complications in the two groups. RESULTS: Prematurity was lower in reduced pregnancies (95.5% in triplets versus 53.5%), especially between 24 to 32 weeks' gestation where prematurity was reduced by half. Birth weight was > 450 g higher in the reduced group. The perinatal mortality rate was lower for reduced pregnancies, but this difference was not statistically significant. Five life-threatening maternal complications occurred in triplets, with none in the reduced group. CONCLUSIONS: Selective terminations are effective in decreasing the rate of prematurity, improving fetal growth, and avoiding maternal complications. The procedure thus could be used in triplet gestations. The ultimate decision should be taken by the couple who must be well informed of the risks of the procedure before deciding.

Influence of the frequency of gonadotropin-releasing hormone (GnRH) administration on ovulatory responses in women with anovulation.

In attempt to optimize gonadotropin-releasing hormone (GnRH) treatment of anovulation, we compared the effect of intravenous GnRH administration at three pulse intervals (PI) during 63 cycles in 30 anovulatory patients who had: (1) amenorrhea secondary to anorexia nervosa (group I: 10 patients, 21 cycles); (2) unexplained anovulation with normal to high luteinizing hormone plasma levels (group II: 12 patients, 24 cycles); and (3) polycystic ovarian disease (PCOD) (group III: 8 patients, 18 cycles). Ovulation was achieved more frequently in group I (85%) than in group II (41%) or in group III (50%). In both groups I and II, the frequency of ovulatory responses was not different with the PI used, and 6 of the 17 women treated for infertility conceived; 3 with 90-minute PIs, 2 with 64-minute PIs, and 1 with 128-minute PIs. In women with PCOD, seven of the nine ovulatory responses and three pregnancies were obtained with 128-minute PIs. The overweight women with PCOD did not respond reliably to GnRH at the doses used, i.e., 4 to 15 micrograms per pulse. In all groups, the urinary estrone and estradiol preovulatory peak, duration of luteal phase, progesterone levels, and preovulatory follicle diameter were unrelated to the frequency of GnRH administration.

Ovarian stimulation by a combination of a gonadotropin-releasing hormone agonist and gonadotropins for in vitro fertilization.

In the first of two studies, 20 patients were selected on the basis of tubal infertility and were randomly assigned to two groups receiving different ovarian stimulation protocols. In group A, 10 patients were given follicle-stimulating hormone (FSH), FSH was continued until the criteria for human chorionic gonadotropin (hCG) administration were satisfied. In group B, 10 patients received Buserelin (0.3 ml twice a day subcutaneously) for 14 days to induce pituitary desensitization. Stimulation with FSH was then started, and Buserelin treatment was continued until hCG administration. In the second study, patients were included if they had had at least two previous attempts at ovarian stimulation that failed to reach the stage of follicular aspiration. Ovarian stimulation was conducted with a combination of Buserelin and human menopausal gonadotropin. Use of the gonadotropin-releasing hormone (GnRH) agonist in in vitro fertilization increased the number of oocytes collected, the fertilization rate, the length of the luteal phase and the pregnancy rate. The GnRH agonist also contributed to a generally better ovarian response in patients whose estradiol production had previously responded poorly to conventional ovarian stimulation protocols.

Prenatal diagnosis of an abdomino-pelvic hydrometrocolpos; a case report.

The authors describe a case of prenatal diagnosis of hydrometrocolpos performed at 35 weeks of ammenorhea. Diagnosis was based on fetal images of a rounded, solid, pelvic mass increasing rapidly, which evoked vaginal and uterine distension. No associated anomaly was found. This very unusual genital malformation required treatment at birth. This case shows that hydrometrocolpos can be evidenced by prenatal ultra-sonography allowing early treatment and prevention of complications.

Early prenatal diagnosis of congenital cystic adenomatoid malformation of the lung (Stocker's type I); a case report.

A congenital cystic adenomatoid malformation was diagnosed by ultrasound examination at 20 week's gestation. The entire right lung was cystic and elements of poor prognosis such as hydrops fetalis and polyhydramnios were present. After verification of the karyotype, abortion was performed and autopsy confirmed prenatal findings and Stocker's type I. Cystic congenital adenomatoid malformation of the lung is a rare form of congenital pulmonary disease. Our case shows that this malformation can be accurately diagnosed during the midtrimester of pregnancy by ultrasound examination. Ultrasound examination permits an evaluation of the three types described by Stocker and may reveal certain lesions associated with poor prognosis, such as anasarca or polyhydramnios. Also, it offers the possibility to save some fetuses by surgical decompression in the immediate postnatal period, or to terminate earlier pregnancies by abortion.

Immunogenetic study of couples with recurrent spontaneous abortions.

OBJECTIVES: Clinical observations suggest that genetic and immunologic disparity could be a factor in fecundity. The HLA system (HLA) is polymorphic and TLX (Trophoblast Lymphocyte Cross-Reactive), which is also polymorphic, seems to be linked to it. The immunologic hypothesis follows that excessive HLA and TLX-sharing could explain the rejection of a semi-allogenic blastocyst. Study objectives are therefore twofold; To determine whether or not there is significant HLA-sharing between spouses with unexplained recurrent spontaneous abortions (RSA) and to determine whether or not there is an association between some HLA specificities and RSA. STUDY DESIGN: The study includes only Caucasian couples that have had three successive spontaneous abortions. These were distributed in two groups: Group E: 18 couples either with known aetiology or with secondary RSA; Group U: seven couples with unexplained primary RSA; Control group C: 21 couples with at least two children and no spontaneous abortions. Tissue typing for HLA-A and B molecules was performed using serotyping methodology based on lymphocytotoxicity reaction. The different DRB1 alleles (class II) were determined by oligotyping with a non-radioactive reverse dot-blot methodology. RESULTS: Statistical comparison shows that the number of couples without shared specificity is not significantly different between the three groups for each locus independently and for the set of three. Our results show also that the allelic frequencies are not significantly different between the three groups. CONCLUSIONS: There is no higher HLA-sharing in couples with RSA than in fertile couples. Similarly, no particular HLA specificity can be associated with the RSA.

Amniocentesis before 15 weeks' gestation: technical aspects and obstetric risks.

In a prospective case-control study, early amniocenteses (EAC, n = 242) at between 12 and 14 weeks gestation, were compared with standard amniocenteses (SAC, n = 242) performed at between 15 and 24 weeks gestation. The medical records of these 484 cases were reviewed for indications, success rate, color and volume of amniotic fluid, gestational age, number of needle insertions, location of the placenta, culture failure rate, obstetric complications and therapeutic abortion rate. There were no significant differences between the two groups in success rate, in culture success rate or in the outcome of the pregnancies. The volume of the sample taken was smaller in the EAC patients (P < 0.001), and therapeutic abortions were performed significantly earlier (P < 0.02.) Results show that EAC is feasible from 11 weeks' gestation, and can be performed for the usual indications as an alternative to chorionic villus sampling. In the near future, cytogenetic techniques will enable results to be obtained in less than a week.

Favourable outcome in 33 triplet pregnancies managed between 1985-1990.

In this paper, we describe the outcome of 33 triplet pregnancies referred to us between 1985 and 1990. They were managed as follows: management at home as soon as the diagnosis was made, then hospitalization at 28 weeks' gestation. Progesterone and beta-mimetics were administered daily, a cesarean section was always performed. One late abortion occurred at 21 weeks. The rate of prematurity was 90.6%, mean gestational age at delivery was 34.1 +/- 3 weeks, and 62.5% of deliveries occurred between 34 and 37 weeks. Ninety-four fetuses were delivered alive. Mean birth weight was 1880 +/- 410 g. Fetal growth retardation rate was 61.8%, including 28 infants under the third centile and 31 under the 10th centile. Perinatal death rate was 4.16% including 2 in utero deaths and 2 neonate deaths. All infants are healthy except for one child with severe mental retardation. These results show that triplet pregnancies can be safely managed, and that selective first-trimester reduction in triplet pregnancies does not appear to be necessary.

[Enzymatic determination of urinary estrogens. A 5-year experience in a hospital milieu]. / Dosages enzymatiques des estrogènes urinaires. Une expèrience de cinq ans en milieu hospitalier.

The enzymatic method for urinary estrogens determination from Nicolas et al. has become a useful tool for the management of infertility problems. It can be used for: investigation of ovarian by establishing the urinary estrogens profile during menstrual cycle, useful to: understand anomalies of the spontaneous cycle, explain some therapeutic failures during IVF attempts or artificial inseminations (AID or AIC); prediction of failures during IVF attempts during spontaneous cycles, and monitoring ovarian response during stimulated cycles in order to determine the trigger with hCG; monitoring ovulation during induction of ovulation in anovulatory patients stimulated with various drugs (clomiphene citrate, pure FSH combination of FSH and LH, GnRH ou analogs...) under various conditions of prescription and administration (oral, IM, intermittent pulsatile administration with portable pump with or without hypophyseal down regulation). This technique allows also exploration of androgens after changing main androgens (delta 4 A, T, DHEA, DHEA S) into estrogens through the action of placental aromatase, as well as appreciation of aromatase activity of some tissues in the presence of androgenic substrates. This paper gives the conclusions after 5 years of practice with this method and summaries different works published by the biologists who developed the method and by the clinicians who used its results.

[Therapeutics basis of threatened abortions (author's transl)]. / Bases thérapeutiques des menaces d'avortements.

The diverse hormonal and vascular medications are studied in the way of their mechanism of action, of their efficiency and their side effects on the mother as well as on the fetus. Neither definite argument, nor important statistical study has been made after elimination of all genetics and chromosomic anomalies. beta-mimetic, alphablocking and progesterone medications are the most efficient and certainly the less dangerous for the fetus.

[Action of Parlodel on the preovulatory peak of estrogens and the ovulatory response of patients with abnormal ovulation and normal blood prolactin]. / Etude de l'action du Parlodel sur le pic préovulatoire d'estrogènes et la réponse ovulatoire des patientes ayant une anomalie de l'ovulation avec normoprolactinémie.

Bromocriptine, a dopamine agonist, is well known for its inhibitory action on prolactin secretion. Its action on other hypophyseal secretions, particularly on the gonadotrophins FSH and LH can indicate use of Parlodel as a stimulatory agent for induction of ovulation even in cases of normal prolactinemia. 129 normoprolactinemic patients with a defect of the preovulatory estrogen rise have been treated over a period of 3 months. 63% of the patients exhibited a positive response to bromocriptine, either because a pregnancy started or because preovulatory E1+E2 became normal. The rate of "responders" is increased among those patients who had conservation of spontaneous menses at the start of therapy. Conclusions of the study are that Parlodel has a place among treatments of ovulation defects. Its genuine efficacity must be confirmed by a controlled study against placebo and other confirmed treatments like antiestrogens.

[Serial levels of HLP, SP1, SP3, and different proteins in pregnancy compared for their prognostic value (author's transl)]. / Valeur comparée du dosage sérique de HLP, SP1, SP3 et de diverses protéines au cours de la grossesse.

A systematic study was carried out on a thousand samples in order to study the distribution of the levels of HPL, SP1 and SP3 in pregnancy. Levels of alpha feto-protein and of alpha antitrypsin as well as of orosomucoid were also studied but only in high-risk pregnancies. When a retrospective study had been carried out after delivery with the object of finding out the value of these levels it was shown that only the levels of SP1 and HLP were useful prognostically. SP1 levels were more reliable apparently as an indicator of feto-placental function. (HLP is the equivalent of HPL human placental lactogen. HP1 is pregnancy specific beta 4-glycoprotein and SP3 is alpha 2-acute phase glycoprotein).

[Fetal growth retardation: prevention. Review of the literature]. / Hypotrophie foetale: prévention. Revue de la littérature.

The principle underlying preventive treatment of fetal intrauterine growth retardation can only be considered after defining various groups that are at risk and early screening based on the obstetric history, biological tests, and recently using flow rates with Doppler techniques. The use of aspirin in preventive treatment of growth retardation originates in the pharmacological properties of its molecule which allow the re-establishment of a balance of the prostoglandins. Numerous authors have studied clinical effects, its harmlessness as well as the true indications for its use. As there have been no control studies the theoretical possibilities of using Beta-Mimetic drugs has not been tested. The use of ultrasound has made it possible to try to see whether there is an improvement in the fetal state of well-being when oxygen therapy is used by the mother as it is in certain extremes to see what effect it has on placental function. Its use as an effective prophylactic has not yet been demonstrated. Promising lines of research could be assessing the effects of immunological treatments that have already been suggested (especially gammaglobulin transfusions). They have been used prophylactically with success but the series are small for well defined immunological indications.

[Fetal growth retardation: physiopathology. Review of the literature]. / Hypotrophie foetale: physiopathologie. Revue de la littérature.

Fetal hypotrophy or intrauterine growth retardation is an important cause of fetal and neonatal mortality and a real cause of iatrogenic prematurity. When pregnancy is progressing normally there are histological changes in the spiral arteries with an equilibrium between the endothelial prostacyclin and platelet thromboxane on the one part and peroxides and Vitamin E on the other part. This allows uteroplacental circulation to flow rapidly and at a low pressure. Furthermore immunological tolerance of the mother's system in the relationship to her embryo plays a part in bringing about this special haemodynamic state. The physiopathology of retarded growth stemming from the blood vessels brings into play multiple mechanisms. The first cause is a defect in placentation which is shown up as insufficient trophoblastic invasion in the second stage. This brings about endothelial dysfunction with disappearance of the normal equilibrium of the prostaglandins and an alteration in the physiological equilibrium between the peroxides and a natural antagonist, which is vitamin E. Immunological disturbances have also been considered following studies on the immunohistochemistry and with the frequent association of obstetrical vascular complications together with phospholipid specific autoantibodies.

[RU 486 and induction of labor in 3d trimester pregnancy interruptions. Preliminary clinical studies]. / RU 486 et déclenchement du travail dans les interruptions du troisième trimestre de la grossesse. Etude clinique préliminaire.

The authors report 12 cases of induction of labour which was carried out with the help of RU 486 in the 3rd trimester of pregnancy (mean duration of the pregnancy 34.2 weeks). Nine cases had malformed fetuses and 3 cases had normal infants. In 6 cases out of the 12 delivery took place within 48 hours after RU had been administered by itself and in 3 cases induction with Syntocinon was helped when RU was given beforehand. In 3 cases the live-born children showed no secondary ill effects.

[Influence of epidural anesthesia on the progression of labor in primiparas]. / Influence de l'anesthésie péridurale sur le déroulement du travail chez la primipare.

A comparative study was carried out on 363 primiparas at the University Hospital of Montpellier to assess what influence epidural anaesthesia had on the number of instrumental deliveries that had to be carried out in our service and in the way it is conducted. This study shows that the increase in the number of instrumental deliveries found in women who deliver under epidural anaesthesia was mainly due to the abnormal obstetric conditions for which the epidural anaesthetic was anyhow given. There was only a small increase in the numbers that had to be delivered instrumentally in those women had epidural anaesthesia "for comfort". This was not particularly significant with anterior presentations.

[Experimental study of uterine hypoplasia. II. Effect of treatment with beta mimetics]. / Etude expérimentale de l'hypoplasie utérine. II. Influence du traitement par un bêta-mimétique

After we had made rats' uteri hypoplastic by surgical interference with their blood supply we carried out a second part of our study by treating the animals that had been operated on with a beta-mimetic substance in order to lessen or counter completely the effects of surgical devascularisation. From our results we can conclude in a statistically significant proportion of cases that the effects of devascularisation are cancelled out by the treatment. These facts are explained by taking into account the specific pharmacological effects on the uterus of beta-mimetic substances.

[Experimental study of uterine hypoplasia. I. Influence of the vascular factor]. / Etude expérimentale de l'hypoplasie utérine. I. Influence du facteur vasculaire

The purpose of the experiment was to prove the importance of the vascular factor in uterine hypoplasia. The animal that was chosen was the rat. The method that was used consisted of devascularisation of one of the two uterine cornua. This was done without altering the blood supply to the ovaries when the animals were 7 weeks of age, which is the immediate prepuberty stage. The results that were obtained were significant whether they were looked at macroscopically, microscopically or by weight. In experimental conditons the hypoplasia was obtained solely due to interference with the blood supply which was carried out surgically.

[Estrogen receptors in uterine fibromyomas]. / Les récepteurs des oestrogènes dans les fibromyomes utérins.

The authors have sought the existence of cellular hyper-receptivity in susceptible cells in order to explain the transformation of normal uterine muscle fibres into tumours, because of the absence of true biological proof of hyperoestrogenization in fibromyomata. The total of uterine receptors for oestradiol (the total number of accessible receptors or those in which endogenous oestrogens had been taken up) were measured in normal myometrium and in fibroids removed at myomectomy or at hysterectomy. The oestradiol receptors are significantly raised in fibromyomatous tissue when the results are expressed as femtomoles per mg. of protein. All the same, there is no significant difference to be found when the results are expressed in micrograms of DNA, which leads to the supposition that there is no significant difference in the concentration of oestrogen receptors in the two types of cells. The cause of the cellular multiplication of fibromyomatous tissue should therefore be sought at another level.

[Male pseudo-hermaphroditism. Prenatal factors]. / Pseudo-hermaphrodismes masculins. Facteurs anténatals.

The authors report on nine cases of male pseudo-hermaphroditism (MPH) diagnosed at birth. They had a karyotype 46 XY and their external genital organs were ambiguous. Analysing the conditions under which the pregnancies occurred we found that there was primary infertility before the pregnancy in 4 out of 9 cases. There was raised maternal blood pressure in 3 out of 9 cases and one of them led to eclampsia. Three babies were preterm and 7 showed intra-uterine growth retardation (below the 10th centile). In 3 cases there were other birth defects and difficulties in the neonatal stage in 6 (2 with respiratory distress, 1 with birth asphyxia, 1 with infection and 2 with jaundice). The diagnosis was based on cytogenetic analysis, x-ray of the urinary tract, x-ray of the genital organs, plasma testosterone levels and the binding capacity of dihydrotestosterone receptors on fibroblasts of the sexual skin areas (fentomoles/mg DNA). The partial androgen insensitivity syndrome was proven in two cases. These mothers had taken drugs that could potentially cause external genital ambiguity (demegestone and chlorpromazine). In 7 cases the diagnosis could not be arrived at. It is known to be very difficult to find an aetiology for MPH but the abnormalities of pregnancy and the frequent occurrence of intra-uterine growth retardation suggest that there are metabolic and endocrine upsets so that fetal malnutrition could play a role in poor external genitalia development. It should be possible to set up a large multicentric study in order to acquire more data and work out the factors that lead to MPH and their relationship to one another.