[Ultrasound appearance of the area of uterine closure in asymptomatic patients at 48 hours of uneventful cesarean section]

OBJECTIVE

It seeks to assess the appearance of the hysterorrhaphy area and seeks hematoma in asymptomatic patients at 48hours of their cesarean.

METHOD

It is common to see, ultrasound or CT scan, collection of images next to the hysterorrhaphy area in symptomatic patients after cesarean. Their interpretation remains difficult which led us to propose a prospective study looking for an evocative image collection or hematoma in asymptomatic patients at 48hours of their cesarean. It was directed suprapubic and transvaginal pelvic ultrasound with study area hysterorrhaphy and inter-uterine bladder space.

RESULTS

The suprapubic ultrasound examination was performed in 31 asymptomatic patients after collecting their written consent. Twenty-eight patients also received an endovaginal examination. The studied area was easily identified by visualizing the path of hysterotomy and hyperechoic aspect of the hysterorrhaphy. In 28 cases there were no abnormal image in front of the hysterorrhaphy area. In 3 cases, an evocative image of a haematic collection was displayed and measured a maximum of only 49mm long axis with a weak Doppler signal. The exam was very well tolerated by patients, especially by transvaginal route. Also the duration of ultrasound never exceeded 58seconds and remained fastest vaginally.

CONCLUSION

This preliminary work to a prospective double cohort (symptomatic patients and asymptomatic patients) has clarified the technique to use and focus in the search for a collection next to the hysterorrhaphy area. Ultrasound examination postoperatively, especially vaginally, is very fast, well tolerated with satisfactory image quality. Finally in this cohort of asymptomatic patients, it was very unusual for a collection, confirming the credit to be given to this type of image in case of symptoms after cesarean.

[Record of the role given to members of the psychological professions in the French Multidisciplinary Prenatal Diagnosis Centers (CPDPN)]

AIM

Create a record of the role given to members of the psychological professions in CPDPN Centers (multidisciplinary prenatal diagnosis). After more than 10 years in operation, describe the work methods of the different centers and their members, evaluate the possible diversity of practices and clarify the scope of interventions used by psychologists with patients and members of the CPDPN.

METHOD

A descriptive survey consisting of 71 questions sent to psychologists, paediatricians and psychiatrists involved with the 48 CPDPN Centers in France. The main parameters studied are the means used by the CPDPN and their organization in the field of psychology, pre-medical counseling for the termination of pregnancy (IMG), conditions of hospitalization and post-IMG counseling.

RESULTS

The survey revealed a high-level of homogeneous practices in the French CPDPN Centers between members of the medical and psychological professions, through joint consultations, ethical committees or specific case meetings for complex fetal pathologies.

CONCLUSIONS AND PERSPECTIVES

This study has established a working relationship between members of the psychological professions working in the French CPDPN Centers and has led to the creation of a listing/directory, which facilitates the exchange of information. Video-conferencing is currently being considered in order to share respective practices.

Discordant sex in monozygotic XXY/XX twins: a case report

We report a case of discordant phenotypic sex in monozygotic twins mosaic 47,XXY/46,XX: monozygotic heterokaryotypic twins. The twins presented with cognitive and comprehension delay, behavioural and language disorders, all symptoms frequently reported in Klinefelter syndrome. Molecular zygosity analysis with several markers confirmed that the twins are in effect monozygotic (MZ). Array comparative genomic hybridization found no evidence for the implication of copy number variation in the phenotypes. Ultrasound scans of the reproductive organs revealed no abnormalities. Endocrine tests showed a low testosterone level in Twin 1 (male phenotype) and a low gonadotrophin level in Twin 2 (female phenotype) which, combined with the results from ultrasound examination, provided useful information for potentially predicting the future fertility potential of the twins. Blood karyotypes revealed the presence of a normal 46,XX cell line and an aneuploïd 47,XXY cell line in both patients. Examination of the chromosome constitutions of various tissues such as blood, buccal smear and urinary sediment not surprisingly showed different proportions for the 46,XX and 47,XXY cell lines, which most likely explains the discordant phenotypic sex and mild Klinefelter features. The most plausible underlying biological mechanism is a post-zygotic loss of the Y chromosome in an initially 47,XXY zygote. This would result in an embryo with both 46,XX and 47,XXY cells lines which could subsequently divide into two monozygotic embryos through a twinning process. The two cell lines would then be distributed differently between tissues which could result in phenotypic discordances in the twins. These observations emphasize the importance of regular paediatric evaluations to determine the optimal timing for fertility preservation measures and to detect new Klinefelter features which could appear throughout childhood in the two subjects.

[Rupture of membranes in case of internal podalic version: a risk for cesarean section on the second twin]

OBJECTIVES

To evaluate if internal version with ruptured membranes is a risk factor of cesarean section for the second twin.

PATIENTS AND METHODS

Two hundred and fifty-nine twins vaginal deliveries after 33 weeks of gestation from 1997 to 2009 in a level 3 maternity. A retrospective case-control study comparing two groups: cases of cesarean section on second twin and five twins vaginal deliveries following the case. Active management of the second twin delivery was performed with a short intertwin delivery.

RESULTS

Eleven cesarean sections on the second twin were performed (4.2%). The main indication was failure of internal version. The risk of cesarean section was significantly greater when the internal version was performed with ruptured membranes (OR: 25.4 IC 95% [2.3-275.7] P<0.003) and when intertwin time delivery interval was increased (8.1±5.1 vs 16.7±6.3, P<0.001).

DISCUSSION AND CONCLUSION

The rupture of amniotic membranes before or during the internal podalic version is associated with a risk of failure and cesarean for the second twin. We recommend to perform the internal podalic version with unruptured membranes according to the French recommendations.

[National Survey of the management and delivery of the unicicatriciel uterus in France in 2009]

OBJECTIVES

To audit French maternity units' obstetric procedures in delivering women who have undergone previous caesarean section.

MATERIAL AND METHODS

[corrected] Survey by questionnaire collecting the obstetrical practices about agreement and methods of delivery of women with previous caesarean section in France in 2009. The questionnaire was sent by email to 472 private and public maternity units of grades 1, 2 and 3.

RESULTS

One hundred and seventy-five units (37%) replied, about 305,710 new-borns representated, few private maternity units answered (12.6% of the answers), despite their accounting for 30.2% of obstetric work; 50.9% had no written policy for the management of patients with previous caesarean; 53.1% of units relied on written consent from women attempting vaginal delivery after previous caesarean. The documentation concerning previous caesarean section was considered important by 73.1% of units. Rates for acceptance of attempted vaginal delivery were as follows: after a transverse lower uterine segment incision - 100% of maternity units; after a transverse corporeal incision - 30.3% of units and after a vertical incision - 25.1% of units; 55.4% of maternities induced labour after a previous caesarean section, 29.9% of them with prostaglandin E2; 64% used internal tocometry. Radiopelvimetry was a routine examination for 55.9% of grade 1 units, compared with 13.5% of grade 3 (P=0.000035). Induction was practised by more grade 3 units (78.3%) than grade 1 units (44%) (P=0.009). No team acknowledged carrying out subsequent caesarean delivery as a matter of principle.

CONCLUSIONS

This national survey, statistically representative in terms of the numbers of deliveries, gives an objective view of different practices, according to type and grade of maternity unit in France, in 2009. The data indicate that it is desirable to devise specific recommendations in order to harmonise management, bearing in mind the frequency of caesarean sections.

Accuracy of prenatal three-dimensional ultrasound in the diagnosis of cleft hard palate when cleft lip is present

OBJECTIVE

To investigate the accuracy of prenatal axial three-dimensional (3D) ultrasound in predicting the absence or presence of cleft palate in the presence of cleft lip.

METHODS

Between March 2005 and January 2009, there were 81 cases with a prenatal two-dimensional (2D) ultrasound screening diagnosis of unilateral or bilateral cleft lip at 22-25 weeks of gestation referred to our tertiary care center. Of these, 79 fetuses were included in this prospective study and two were excluded. Axial 3D ultrasound imaging of the fetal palate was performed and the diagnoses were compared with clinical findings at delivery. The frequencies of intact and cleft palate, the degree of association between the prenatal predictions and postnatal findings and the probability of detection of cleft lip and palate were determined.

RESULTS

Of 79 prenatal predictions, 77 (97%) were correct and the association between the prenatal predictions and postnatal findings was strong. The sensitivity for detection of cleft lip and palate within this high-risk population was 100% and the specificity was 90%. In one of the excluded cases, the palate could not be visualized due to a fetal prone position. There were chromosomal anomalies in 4% of cases and associated structural or growth anomalies in 23%, termination of pregnancy was carried out in 4% and intrauterine fetal demise occurred in 3%.

CONCLUSION

Axial 3D ultrasound of the fetal palate has high accuracy in identifying prenatal cleft palate when cleft lip is diagnosed at mid-trimester 2D ultrasound screening.

Prenatal management of congenital infantile fibrosarcoma: unexpected outcome

We report the case of a large leg tumor in a fetus at 36 weeks of gestation. The tumor's location, ultrasound characteristics and magnetic resonance imaging (MRI) findings enabled a prenatal diagnosis of congenital fibrosarcoma and allowed us to establish the prognosis. After multidisciplinary discussion, it was decided that the pregnancy should continue to 38 weeks, with surgery or neo-adjuvant chemotherapy scheduled after delivery. Unfortunately, the tumor unexpectedly burst in utero and the newborn died of the consequences of hemorrhagic shock, despite rapid amputation. Histological examination confirmed the nature of the tumor. The prognosis of congenital fibrosarcoma is generally good when there are no metastases. MRI is key to establishing a prenatal diagnosis. However, rupture of the tumor can result in fatal hemorrhaging and the pregnancy should be monitored closely before scheduled delivery.

Prenatal assessment of the normal fetal soft palate by three-dimensional ultrasound examination: is there an objective technique?

OBJECTIVES

To describe a three-dimensional (3D) ultrasound technique for assessing the fetal soft palate.

METHODS

A prospective study conducted from April to December 2006 included 87 fetuses in a low-risk population. Fetal ultrasound scans were performed between 21 and 25 weeks of gestation to determine the normal 3D ultrasound view of the fetal soft tissues of the palate. The sonographers used a 30 degrees-inclined axial 3D view of the fetal palate. Ultrasound images obtained in this view were compared with fetopathological specimens of the same gestational age by two observers, both pediatric surgeons. Each observer indicated whether they thought that the uvula or the velum could be detected, and the differences in responses between the observers were assessed.

RESULTS

The frequencies of detection of the uvula and velum of each observer varied between 80% and 90%. The observers showed a significant difference in judging the visualization of the uvula, but not in judging the velum.

CONCLUSIONS

A 30 degrees -inclined axial 3D ultrasound view seems to be effective in assessing the integrity of the fetal soft palate.

Optimizing the outcome of pregnancy in obese women: from pregestational to long-term management

The obesity epidemic is of some concern in women of reproductive age. Maternal obesity is associated with many pregnancy complications, especially gestational diabetes and hypertensive disorders of pregnancy. Delivery in obese women is characterized by a high caesarean-section rate and an increased risk of anaesthetic and postoperative complications. Weight retention after birth may increase the risk of type 2 diabetes in the long term. Foetal risks include macrosomia, malformations and increased perinatal mortality, with the long-term infant health marked by a higher risk of obesity and metabolic disorders. Optimal management includes preconception counselling, pregravid weight-loss programmes, monitoring of gestational weight gain, repeated screening for pregnancy complications and long-term follow-up to minimize the social and economic consequences of pregnancy in overweight women.

Prise en charge d'épisodes récidivants de pancréatite aiguë par nutrition parentérale exclusive pendant la grossesse. Cas clinique et revue de la littérature

We report on a 35-year-old woman who underwent at 15 weeks of pregnancy exclusive parenteral nutrition for recurrent episodes of acute pancreatitis. She had a pancreatico-jejunal anastomosis stenosis secondary to cephalic duodenopancreatectomy. Nocturnal exclusive parenteral nutrition was used 79 days during pregnancy and 12 days during post-partum. The fetal growth was normal and the foetal well-being was normal. She presented cholestasis at 30 weeks of pregnancy treated medically. She delivered at 33 weeks of pregnancy by cesarean section a healthy baby girl with normal birth weight.

Sonographic assessment of normal fetal palate using three-dimensional imaging: a new technique

OBJECTIVES

The aim of this study was to describe a novel three-dimensional (3D) ultrasound rendering technique to examine the normal fetal posterior palate and to assess its correspondence with the real fetal anatomy.

METHODS

A prospective longitudinal study was conducted from January to October 2005 and included 100 fetuses in a low-risk population. Fetal ultrasound examinations were performed at 17, 22, 27 and 32 weeks' gestation to determine the normal 3D ultrasound view of the fetal palate at different gestational ages. The ultrasound scans were performed using the strict anterior axial plane of the starting reconstruction volume and the underside 3D view of the fetal palate. The 3D view of the fetal palate was compared with the normal anatomical view of the fetal palate obtained by surgical fetopathological examination of fetuses at the same gestational ages. The sonographic visualization rates of seven defined anatomical landmarks of the fetal palate were computed for each gestational age. The visualization rates across gestational ages were compared by use of the Cochrane Q test. The reliability of detection of each anatomical landmark across gestational ages was determined by Cronbach's Alpha.

RESULTS

In all cases a 3D ultrasound view of the fetal maxilla and secondary palate was obtained at each period of gestation and corresponded well to the fetal anatomical specimens. The seven defined anatomical landmarks of the fetal palate were identified in 42-100% of cases. The visualization rates across gestational ages were significantly different in five of these anatomical landmarks. These differences can be explained by different developmental processes of these anatomical structures. The overall reliability of visualization across the gestational ages for the anatomical landmarks was medium to very high (0.73-0.96), except for the landmark interpalatal suture which was low (0.48).

CONCLUSIONS

This technique of anterior axial 3D view reconstruction of the fetal palate seen by an underside view can provide unique diagnostic information on the integrity of the secondary palate. This innovative, simple and rapid technique may become the reference technique in ultrasound investigation of the fetal palate, and should be of value in diagnosing isolated secondary cleft palate or palatal involvement when cleft lip and alveolus are diagnosed.

Prevalence of HFE mutations in people from North Africa living in southern France

The two main mutations of the HFE (haemochromatosis) gene, C282Y and H63D, were found previously to be rare or absent among Africans. Dried blood samples of 1276 newborns from southern France were analysed for both HFE mutations, and the origins of the four grandparents of each newborn were recorded. The allele frequency of C282Y and H63D was 3.0% +/- 0.7% and 16.9% +/- 1.5% respectively. In a subgroup of 171 newborns with four North African ancestries (mainly from Morocco and Algeria) the allele frequency was 0.9%+2.5%-0.2% for the C282Y and 13.2% +/- 3.6% for H63D. HFE mutations are not absent in individuals with North African origins living in southern Europe. This finding has implications for the diagnosis and screening of hereditary haemochromatosis in these populations.

[Insulin therapy in type 1 diabetes for and during pregnancy: by which means and for which objectives?]

Clinical data in the 1980s showed a close relationship between the conceptional glycated hemoglobin and the occurrence of spontaneous early abortions and fetal malformations. Blood glucose level during pregnancy was similarly correlated with the risk of fetal macrosomia, due to significant links between birthweight, fetal hyperinsulinemia and mean maternal blood glucose. Tight blood glucose control from conception to term was shown to be able to lower the risk of fetal malformations and perinatal mortality to that of the offspring of a non diabetic mother. Prerequisites include: 1) contraception until tight blood glucose control, 2) close partnership between diabetologist and obstetrician, 3) assessment of diabetic complications. Seldom, coronary heart disease or advanced nephropathy contraindicate pregnancy. Uncontrolled proliferative or pre-proliferative retinopathy, or macular edema, are temporary contraindications to pregnancy. Laser photocoagulation must then be performed before tightening blood glucose control. A complete review of diabetes management is associated with therapeutic intensification. Blood glucose objectives allow as limits: 70 to 100 mg/dl before meals, up to 140 mg/dl one hour and 120 mg/dl two hours after meals. HbA1c allowing conception is close to 7%. Blood glucose monitoring requires 6-7 measurements per day. The most efficient insulin regimens include 3 to 4 shots per day. The distribution between regular and NPH or lente insulins is adapted individually. Lispro insulin, now appearing as safe, may be used to improve post-meal blood glucose control. Insulin pumps may be useful in case of late-night poor control or frequent hypoglycemic events. Patient acceptance of this option is unavoidable to obtain a benefit. Preconceptional insulin therapy must be maintained until pregnancy term. Follow-up must be intensified after twenty fourth week. Labor and delivery, cesarean section, fetal maturation by corticosteroids and use of i.v. betamimetic drugs require continuous i.v. insulin delivery. The continuation of intensive insulin management in post-partum is encouraged.

The effects of mifepristone on uterine sensitivity to oxytocin and on fetal heart rate patterns

OBJECTIVE

To compare the incidences of tachysystole, hypertonia and fetal heart rate (FHR) abnormalities in women treated by mifepristone plus prostaglandins (PGs), mifepristone alone or PGs alone for an unfavourable cervix.

STUDY DESIGN

In this retrospective study, all women between 37 and 42 weeks were eligible for the study if they had undergone cervical ripening prior to labour induction. In group 1, the women were treated with mifepristone plus PGs (n=103). Group 2 women were treated with mifepristone alone (n=96) and group 3 women with PGs alone (n=100). Incidences of tachysystole, hypertonia and FHR abnormalities were compared.

RESULTS

During induction of labour, tachysystole and hypertonia occurred more frequently in women treated with mifepristone. Severe bradycardia and recurrent late decelerations were more frequent after the initiation of oxytocin in groups 1 and 2 than in group 3.

CONCLUSIONS

In this study, mifepristone increased the incidences of tachysystole, hypertonia and FHR abnormality.

[Evaluation of the benefits brought by pregnancy planning in type 1 diabetes mellitus]

Fetal mortality and morbidity remain dramatically increased in diabetic women. To evaluate the benefit of a preconceptional education combined with a good metabolic control, we compared the outcome of pregnancy in 2 groups of type I diabetic women: group A (n = 21) planned before conception versus group B (n = 40) not planned. Both groups were similar related to the type and duration of diabetes, its complications, age, body mass index and different factors of risk. In group A, HbA1C levels were < or = 3 SD of the normal mean of non diabetic values before conception and during the pregnancy course and > or = 3 SD in group B. We observed a significant reduction (p < 0.05) of the main adverse events regarding fetus outcome (fetal, perinatal and neonatal mortality, malformations) and obstetrical complications in the planned group. These data lead to the need of an extensive policy of early planification of pregnancy in diabetic women.

Rheological properties of fetal red cells with special reference to aggregability and disaggregability analyzed by light transmission and laser backscattering techniques

Blood viscosity factors and fetal erythrocyte aggregability were investigated with light transmission (Myrenne device) during a cross-sectional study of blood drawn in utero by cord venepunctures in 119 normal fetuses between 18 and 39 weeks gestation. There was a progressive increased blood viscosity at native hematocrit (p < 0.01) explained by a gradual increase in both hematocrit (from 33% to 40%, p < 0.05) and Dintenfass' 'Tk' RBC rigidity index (p < 0.05), while plasma viscosity remained constant at 1.18 +/- 0.01 mPa x s as well as the h/eta ratio (188.4 +/- 2.7 mPa(-1) x s(-1)). The RBC aggregation index 'M' remained almost equal to zero (mean value: 0.04 +/- 0.01) before 32 wk gestation and then increased (p < 0.05) until delivery. The upper physiological limit for this parameter before 32 wk (mean +/- 2 SD) is 0.18. The RBC aggregation index 'M1' remained constant during pregnancy at 2.98 +/- 0.26, i.e., the upper physiological limit for this parameter during the intrauterine life (mean +/- 2 SD) is 7.85. Both fibrinogen (r = 0.479, p < 0.05) and albumin (r = 0.494, p < 0.01) correlated with time so that the albumin/fibrinogen ratio remained stable. We then studied with the laser retrodiffusion technique the venous blood of 20 women (18-43 yr, 37-40 wk gestation) and the cord blood of their newborns at birth, comparing RBC aggregation of: mothers (M), maternal RBCs resuspended on newborn plasma (MF), newborn RBCs resuspended on maternal plasma (FM), and newborns (F). Aggregability is higher in M (RBC aggregation time M < MF < FM < F; p < 0.01); RBC aggregation index at 10 s M > MF > FM > F; p < 0.01), with in turn the symmetric inverse picture for the partial disaggregation threshold (M > MF = FM > F). Thus RBC disaggregability is higher in newborns, and suspensions on maternal and newborn plasma suggest that half of this difference in aggregability (and disaggregability) between fetal and adult blood results from plasma factors and another half from erythrocytes.

Multifetal reduction of triplets to twins: a prospective comparison of pregnancy outcome

The aim of this study was to compare the outcome of triplets managed expectantly or by multifetal reduction to twins to assess the potential benefit of fetal reduction. The study design was prospective, comparative and monocentric and the study was conducted in a teaching hospital. Out of 148 women with triplets mostly obtained after infertility treatment, 83 were expectantly managed while 65 chose reduction to obtain twins. Main outcome measures were fetal loss before 24 weeks, premature deliveries before 28, 32 and 34 weeks, rate of low birthweight infants and neonatal and perinatal mortality rates. The fetal loss rate before 24 weeks did not differ between the ongoing group and the reduced group (6 versus 5.4%). Reducing triplets was associated with a significantly lower incidence of the following: prematurity before 28, 32 and 34 weeks (P < 0.001), low birthweight infants whose weights were under the third centile (P < 0.002) and infants whose weights were less than 1000, 1500 and 2000 g (P < 0.001). Neonatal (although apparently lower in the reduced group) and perinatal mortality did not significantly differ. Our results indicate that reduction of triplets to twins is effective to improve preterm birth and fetal growth.

B19 parvovirus-induced fetal hydrops:good outcome after intrauterine blood transfusion at 18 weeks of gestation

We report a successful treatment of a B19 parvovirus-induced fetal hydrops diagnosed at 16 weeks of gestation. This disease could be corrected by means of a unique intraperitoneal blood transfusion performed at 18 weeks, once diagnosis was established. The delivery occurred at 36 weeks, leading to the birth of a healthy baby. This case suggests that transfusion should be attempted, as the spontaneous fetal recovery remains uncertain and shows that intraperitoneal blood transfusion is an effective therapeutic option of the B19 parvovirus-induced anemia, in the absence of a viral myocarditis.

A randomised evaluation of two techniques of management of the third stage of labour in women at low risk of postpartum haemorrhage

OBJECTIVE

To determine whether early placental drainage plus cord traction reduces the incidences of manual removal and blood loss, and to determine the risk factors associated with blood loss after delivery.

DESIGN

Prospective randomised study.

SETTING

University teaching hospital, Montpellier, France.

METHODS

A randomised study compared 239 women who had placental cord drainage plus cord traction with 238 women with expectant delivery. The need for manual removal of the placenta and the drop in haemoglobin after delivery were assessed. The duration of the third stage of labour and the time between birth and the beginning of perineal suturing were measured. Statistical analysis used the paired t test for continuous variables, the Kruskal-Wallis test for nonparametric data and chi2 test for categoric variables. Stepwise logistic regression analyses were performed with a drop in haemoglobin as the outcome variable.

RESULTS

No significant difference was found in the two groups with regard to the incidence of manual removal of retained complete or incomplete placenta or postpartum haemorrhage. The median values of the duration of the third stage of labour, birth-to-perineal suture time and drop in haemoglobin were significantly lower in the cord drainage group than in the control group. After controlling for confounding variables, parity proved to be the only significant predictor of drop in haemoglobin.

CONCLUSION

Cord drainage decreases the duration of the third stage of labour and reduces blood loss but not the incidence of manual removal of the placenta.

Differential effect of N-ethyl maleimide on delta6-desaturase activity in human fetal liver toward fatty acids of the n-6 and n-3 series

The effect of N-ethyl-maleimide (NEM) on delta5- and delta6-desaturase activities and the incorporation of substrates and products into different microsomal lipid classes and phospholipid (PL) subclasses were studied in human fetal liver microsomes, obtained after legally approved therapeutic abortion. Desaturase activities were measured by a radiochemical method using reversed-phase high-performance liquid chromatography (HPLC). After nonphospholipid (NPL) and PL separation on silica cartridges, the radioactivity in different lipids of the NPL group was assessed by two-dimensional thin-layer chromatography, and their fatty acid (FA) composition by gas-liquid chromatography. The PL subclasses were separated, and the distribution of radioactivity between products and substrates was determined in PL subclasses. NEM inhibited the delta5- and delta6-desaturase activities in the n-6 series of FA but not the delta6-desaturase activity in the n-3 series, which suggests the existence of two distinct delta6-desaturases, one for the n-6 series and another for the n-3 series. Whether NEM was present or absent, most of the radioactivity was recovered in the free FA form (about 80%). The desaturation products, obtained in the presence or absence of NEM, were preferentially incorporated into PL, suggesting a channeling of the newly synthesized FA toward microsomal PL. The comparison of the distribution of substrates and products incorporated into the different PL classes showed that most of the labeled FA were incorporated into phosphatidylcholine and to a lesser degree into phosphatidylethanolamine.

Assessment of triplet fetal growth by using cross-sectional analysis of the birth weight

OBJECTIVE

To model the growth of triplets.

METHOD

Statistical analysis using data of a consecutive series of 76 triplet gestations (223 livebirths).

RESULTS

The best model to describe the growth was linear regression (r = 0.76; r2 = 0.577; p < 0.0001; y = -2,858.05 + 139.66x). 34.2% of the sets had an intratriplet discordance rate of at least 25%, and 11.8% of the triplets had a maximum discordance rate over 40%.

CONCLUSIONS

(1) Triplet fetal growth is strongly related to the gestational age; (2) the growth of each triplet in a same set may considerably differ, and (3) the use of singleton curves for triplet growth assessment is inadequate.

[Fetal intraventricular hemorrhage caused by cerebral contusion, and with spontaneous remission. Contribution of MRI]

We report a case of fetal ventricular hemorrhage which occurred at 27.5 weeks gestation and caused by fetal brain contusion after a maternal traumatism. Ultrasound examination evidenced ventriculomegaly and an intraventricular clot which were confirmed by MRI. We discuss the interest of combining ultrasound and MRI of the fetal brain for the investigation and follow-up of fetal brain trauma. The patient gave birth to an eutrophic normal boy. The child is normal at 12 months follow-up.

[Application of the PRINS technique for chromosome examination in fetal cells present in maternal blood]

Both detection and chromosomal analysis of fetal cells present in the maternal circulation can be performed using Histopaque double density gradient centrifugation followed by primed in situ (PRINS) labeling technique. This approach has been tested on blood samples from 15 pregnant women and 6 control donors with primers specific for chromosomes 9, X and Y. The cell separation technique allows recovery of both mononuclear cells and polynuclear cells with a 97% efficiency. PRINS labeling was successful in 100% cells from control blood samples. Among patient samples, 2 "false-negative" results were observed. These preliminary results suggest that the present protocol might be efficient for non-invasive prenatal chromosome analysis.

[RT-PCR in the prenatal diagnosis of rubella. Report of 2 cases]

OBJECTIVE

To confirm the interest of the reverse transcription-coupled polymerase chain reaction (RT-PCR) in prenatal diagnosis of rubella.

PATIENTS AND METHODS

Maternal blood, amniotic fluid and foetal blood specimens collected at 21 to 24 weeks of amenorrhea from two pregnant women with serologically proven rubella infection were tested by RT-PCR and cell culture for detection of rubella virus. Rubella virus-specific IgM antibodies were also assayed in foetal blood.

RESULTS

In both cases, rubella virus was detected in foetal blood by RT-PCR and cell culture, whereas it was not detected in maternal blood. Rubella virus-specific IgM were also detected in foetal blood. In amniotic fluid specimens, rubella virus was detected by RT-PCR in one case and by cell culture in the other one. A termination of pregnancy was carried out in both cases.

COMMENTS

RT-PCR is a rapid test. It could be useful to confirm foetal infection and could represent a criterion for considering a pregnancy termination. However, this technique which is not yet standardized for detection of rubella virus, needs further validation by additional studies.

A short-term supplementation of pregnant women before delivery does not improve significantly the vitamin E status of neonates--low efficiency of the vitamin E placental transfer

Little is known about lipid-soluble vitamin placental transfer. We supplemented ten pregnant women ranging in age from 26 to 38 years with vitamin E at a daily dose of 1 g dl-alpha-tocopherol acetate for 3 days before delivery. All pregnancies ranged from 37 to 39 weeks of gestation at the time of the study. Maternal blood was first drawn during the week preceding supplementation and then just before the delivery by hysterotomy. Neonatal blood was from cord at birth. Supplementation dramatically increased the plasma and red blood cell vitamin E of the mothers. This was true whatever the expression of the vitamin E content, i.e., plasma lipid-normalized or non-normalized vitamin E, and red blood cell vitamin E related to volume of packed cells or to membrane-phospholipid phosphorus. In contrast, the plasma vitamin E content was very low in neonates (3.51 +/- 0.38 mg/L) and did not significantly differ from that reported in a previous paper, where plasma was drawn from fetal cord blood of pregnant non-supplemented women belonging to the same geographical population (Cachia et al., Am. J. Obstet. Gynecol. 1995; 173: 42-51). This strongly suggests that the transfer of vitamin E through the placental barrier is very low. That the plasma lipid-normalized levels of mothers before supplementation and of neonates did not significantly differ also suggests that the paucity of lipids in the circulating blood of neonates is the cause of the restricted amount of plasma vitamin E. Therefore, the low level of vitamin E in neonates may result from both low maternal placental transfer and neonatal lipid transport peculiarities.

Fetal cells in maternal blood: the use of primed in situ (PRINS) labelling technique for fetal cell detection and sex assessment

Prenatal diagnosis is presently performed following invasive procedures with variable risks of fetal loss; non-invasive procedures using fetal cells in maternal blood would be welcome for the early detection of fetal sex or aneuploidy. We describe a simple and rapid protocol to detect fetal cells and thus to assess fetal sex. In a first step, nucleated blood cells were separated into mononuclear and polynuclear cells using a double density gradient centrifugation. In a second step primed in situ (PRINS) labelling technique was performed to label Y-chromosomes. 15 samples were studied and correct gender assignment was made in 13/15. The number of labelled nuclei was higher in polynuclear cell phases than in mononuclear cell phases. Moreover, the polylobular aspect of labelled nuclei from polynuclear cell phases strongly suggested that they could belong to fetal polynuclear cells. The PRINS technique combines some advantages of FISH, such as visual assessment of in situ chromosome labelling and the powerful specificity and sensitivity of PCR. In association with a simple enrichment procedure it constitutes a rapid protocol for fetal cell detection, non-invasive early prenatal sex assessment, and could further be applied to detect the main viable aneuploidies.

Fatty acid desaturase activities and polyunsaturated fatty acid composition in human liver between the seventeenth and thirty-sixth gestational weeks

OBJECTIVE

The aim of the study was to characterize n-3 and n-6 fatty acid delta5- and delta6-desaturase activities and their time course variations in human fetal liver between the 17th and 36th gestational week.

STUDY DESIGN

Twenty-one biologic samples were obtained after legally approved medical abortion, according to French law. The desaturase activities were measured in the 21 liver samples by a radiochemical method by means of reverse-phase high-performance liquid chromatography. The fatty acid composition (percentage by weight) of liver phospholipids was assessed in 16 samples by gas-liquid chromatographic analysis.

RESULTS

Both delta5- and delta6-desaturase activities were significantly expressed between the 17th and 36th gestational weeks. During the second trimester n-6 fatty acid delta5- and delta6-desaturase activities showed opposite patterns of variation; both then remained stable between the 25th and 36th weeks. Delta6-desaturation was higher in n-3 than n-6 fatty acids and peaked at the 18th gestational week. The percentages of linoleic and docosahexaenoic acids in liver microsomes were positively correlated with the gestation age (P < .01), whereas arachidonic acid remained stable.

CONCLUSION

Significant n-3 and n-6 delta5- and delta6-desaturase activities are expressed in human fetal liver as early as the 17th gestational week and are stable throughout the third trimester. Their theoretic capacity evaluated from in vitro measurements appears lower than polyunsaturated fatty acid requirements and is not directly related to liver microsomal membrane fatty acid composition.

Delta6- and delta5-desaturase activities in the human fetal liver: kinetic aspects

Delta6- and delta5-desaturase activities were studied in human fetal liver microsomes obtained after legally approved therapeutic abortion. Enzyme activities were measured by a radiochemical method using reverse-phase high performance liquid chromatography (HPLC). Free and phospholipid fatty acids were assessed in each liver sample by a combination of thin-layer chromatography (TLC) and gas-liquid chromatography (GLC) procedures. The kinetic measurements showed higher delta6-desaturase activity for the n-3 series than for the n-6 series. Apparent Km of 6.5, 3.9, and 24.5 microM and Vm of 7.5, 9.1, and 24.4 pmol x min(-1) x mg(-1) were obtained, respectively, for 18:2n-6 delta6-, 20:3n-6 delta5-, and 18:3n-3 delta6-desaturases. Beyond 30, 20, and 60 microM of 18:2n-6, 20:3n-6, and 18:3n-3 concentration, respectively, the enzyme activity deviated from Michaelis-Menten kinetics, suggesting an inhibition by excess substrate which is unlikely to occur in vivo as endogenous substrate concentration is much lower. We observed a breakdown in linearity between desaturase activity and microsomal protein concentration beyond 4-5 mg microsomal protein, whatever the enzyme or substrate. Both this phenomenon and the inhibition due to excess substrate should be taken into account in the determination of delta6- and delta5-desaturase activities. Comparison of concentrations of the respective endogenous substrates and the kinetic constants of each enzyme suggested that the higher delta6-desaturase activity observed for the n-3 series than for the n-6 series is not physiologically relevant in human fetal liver.

First-trimester multifetal pregnancy reduction: evaluation of technical aspects and risks from 2,756 cases in the literature

OBJECTIVE

To evaluate the technical aspects, efficacy and safety of first-trimester multifetal pregnancy reduction in the management of multifetal pregnancies, an analysis of the international literature on first-trimester multifetal pregnancy reduction was made.

MATERIALS

Thirty-three studies were selected from an international review of the literature. Total fetal loss rate, risk of fetal loss after the procedure with the different techniques and gestational age at delivery were the main parameters studied. The Kruskal-Wallis test and Mann-Whitney test were used for statistical analysis.

RESULTS

2,756 multifetal pregnancy reductions were performed (2,145 transabdominal, 363 transcervical, and 248 transvaginal procedures). Total fetal loss rates were different: 16.7% for the transabdominal, 24.8% for the transcervical and 10.9% for the transvaginal procedure (p = 0.03). The risk of fetal loss was 12% for the transabdominal, 20% for the transcervical, and 10% for the transvaginal approach at less 24 weeks of gestation (p = 0.04). There was no difference for the gestational age at the time of the procedure, the initial and final number of embryos, and the gestational age at delivery.

CONCLUSION

Because the transvaginal approach seems to be the safer procedure, surgeons may opt for it. The transcervical approach has a high fetal loss rate and should be excluded.

[Early prenatal ultrasonographic diagnosis of fetus in fetu]

Fetus in fetu is a very rare abnormality, and is secondary to a pathological diamniotic monochorionic pregnancy. Its discovery is usually postnatal. We report a case of prenatal diagnosis suspected at 16 gestation's week because of a voluminous omphalocele seen at 12 gestation's week.

[Evaluation of combination RU 486-laminaria tents-misoprostol-peridural anesthesia in second and third trimester induced abortions]

OBJECTIVE

To evaluate a new protocol for mid and third trimester medical termination of pregnancy using RU 486-misoprostol-epidural analgesia.

DESIGN AND SETTING

Monocentric, prospective and descriptive study in a teaching hospital.

MATERIALS AND METHODS

Eighty-three women undergoing legal induced abortion during the second and third trimester. Administration of 600 mg mifepristone 36 hours prior to laminaria tents. 48 hours after RU 486, misoprostol was orally given on a 3 hours basis. Epidural analgesia was systematically performed.

MAIN OUTCOME MEASURES

Induction-abortion interval, median dose of misoprostol, maternal complications, number of fetal autopsies obtained within 24 hours.

RESULTS

The mean induction abortion interval was 3 h for multiparas and 4.45 h for nulliparas. The median dose of misoprostol was 800 micrograms. A uterine rupture on a scarred uterus occurred. The rate of fetal autopsies in cases of malformations within 24 hours reached 96%.

CONCLUSIONS

This protocol allows a safe, rapid, cheap and painless late termination of pregnancy, when compared to other protocols.

Nonimmune hydrops fetalis caused by intrauterine human parvovirus B19 infection: a case of spontaneous reversal in utero

We report a case of spontaneous reversal in utero of hydrops fetalis caused by parvovirus B19 maternal-fetal infection. The route leading to fetal hydrops is not fully understood. Severe anemia with hypoxemia and viral fetal myocarditis have been incriminated. Then the main issue is fetal death or spontaneous abortion. Cases of spontaneous reversal of hydrops fetalis are unusual. Fetal regenerative anemia is a good prognostic factor and emphasizes the place of conservative management.

[Delivery of the overweight woman. Analysis of 115 patients]

OBJECTIVE

Our purpose was to assess the effect of weight gain during pregnancy on labor and delivery. Abnormal pregnancies were excluded from the study to avoid interaction with the management of labor.

POPULATION AND METHODS

A retrospective monocentric case-control study was carried out. We analysed 115 pregnancies delivered in our institution between June 1994 and November 1994. The course of labor was studied in 2 groups of patients: a group of overweight patients and a control group.

RESULTS

In the overweight patients, the frequency of induction of labor (25%) and of obstetrical analgesia (82%) was significantly higher than in the control group (respectively 7% and 64%), as well as the average duration of labour and the average duration of the rupture of the membranes. The rate of cesarean section was higher in the overweight patient group (16.7%) than in the control group (3.7%). The difference was not significant because of the small number of patients.

CONCLUSION

These results show a more frequent requirement of induction of labour, analgesia, and cesarean section in overweight patients. This led us to propose a multidisciplinary management of overweight patients to minimize these different obstetrical risks during labor.

[Trends in therapeutic abortion management from 1986 to 1994]

OBJECTIVE

This study was performed in order to evaluate indications, techniques and maternal risks of medical abortions, and technical difficulties encountered in these procedures.

TYPE OF THE STUDY

A monocentric, descriptive and retrospective study.

MATERIALS AND METHODS

Four hundred seventeen medical abortions (MA) were performed in our fetal medicine Unit between 1986 and 1994, including 117 (28%) performed for maternal reasons and 300 (72%) for fetal reasons. Each indication was discussed in a collegial system and varied protocols of labor induction were used, mainly prostaglandins, RU 486, or feticide. MAIN PARAMETERS MEASURED: They were duration of the labor, maternal accidents, number of the fetal post-mortem examinations, counselling given to the couples. We considered that a MA is correctly managed when the intervention corresponded to the following criteria: expulsion by natural route without uterine damage, an examinable fetus and examination by a foetopathologist.

MAIN RESULTS

Mean rate of MA satisfying our definition was about 45% in 1988 and reached to 74% in 1994. Our results show that the procedure is rarely complicated and that vaginal expulsion can be obtained. The foetopathologist examination rate increased regularly over the period. The mean gestational age of MA due to maternal indications was 14.5 weeks vs 23.9 weeks when dealing with fetal indications. The infection rate is about 6.2%, hemorrhage rate following expulsion was about 5.9% and the rate of uterine rupture was about 0.48%.

CONCLUSIONS

These data suggest that medical abortion need to be evaluated regularly.

[Congenital adenomatoid cystic malformation of the lung and renal polycystosis. A fetal case report and review of the literature]

We observed a plurifocal cystic adenomatoid malformation of the lung, Stocker class II, in a 21-week gestation fetus in association with polycystosis of a solitary medial kidney. There was no other notable abnormally. The caryotype could not be obtained. The association of these two congenital malformations is exceptional, only three similar cases have been reported in the literature. Two other cases of pulmonary adenomatoid malformations associated with nephromegaly with renal hyperlobulation have also been described. Whether this is a fortuitous association or not remains to be determined.

Antenatal diagnosis of congenital toxoplasmosis: evaluation of the biological parameters in a cohort of 286 patients

OBJECTIVE

To evaluate the biological parameters obtained by cordocentesis and amniocentesis in the antenatal diagnosis of congenital toxoplasmosis.

DESIGN

Nine-year retrospective study.

SETTING

Parasitology Laboratory, Department of Obstetrics and Gynaecology and Department of Paediatrics, Centre Hospitalo-Universitaire, Montpellier, France.

PARTICIPANTS

Two hundred and eighty-six pregnant women infected with toxoplasmosis between 7 and 34 weeks of gestation.

METHODS

Detection of abnormalities by ultrasound examination. Detection in fetal blood of Toxoplasma, of specific IgM and IgA and of nonspecific biological markers. Detection in amniotic fluid of Toxoplasma.

RESULTS

Out of 286 antenatal diagnoses, 211 were negative (1st group), 40 were positive (2nd group) and led to 8 medical abortions, and 35 were uncertain (3rd group). In the 1st and 3rd groups respectively, 7 (3.3%) and 5 (14.3%) cases of congenital toxoplasmosis were observed. Overall, 52 cases of congenital toxoplasmosis were detected: 12 were clinically apparent, 36 subclinical (of which 12 were in groups 1 and 3) and 4 were lost to follow up.

CONCLUSION

There is substantial importance in making the diagnosis of toxoplasmosis antenatally in order to limit the number of medical abortions. In our series, the most accurate predictor was the detection of the fetal antibody response (specific IgM and IgA) to Toxoplasma.