Periventricular nodular heterotopia on prenatal ultrasound and magnetic resonance imaging.

OBJECTIVES: To describe the prenatal ultrasound and magnetic resonance imaging (MRI) findings suggestive of periventricular nodular heterotopia (PNH). METHODS: This retrospective case series included fetuses referred to our institution for brain MRI between 2007 and 2012, which were diagnosed with PNH and confirmed by postnatal MRI or autopsy. The type of PNH, associated ventriculomegaly and associated malformations are reported. RESULTS: We included 11 fetuses (nine female, two male) with a mean gestational age at diagnosis of 31 (range, 23-34) weeks. PNH lesions were small and diffuse (n = 7), large and multiple (n = 1) or single (n = 3). A targeted ultrasound examination performed before fetal MRI missed the diagnosis in four cases (one diffuse and three single); a further ultrasound examination performed after MRI diagnosed PNH in two of these four cases. Ventriculomegaly was present in six cases (four unilateral and two bilateral). PNH appeared in all cases as nodules of intermediate echogenicity protruding into the ventricular lumen. In all cases of diffuse PNH, the frontal horns and bodies of the lateral ventricles appeared square in shape on coronal view, with irregular borders on axial view. Associated cerebral malformations were observed in seven cases and included corpus callosal agenesis (n = 4, with additional malformations in two) and retrocerebellar cyst (n = 3). Extracerebral malformations were also present in two cases. Maternal MRI was performed in five of the six cases of isolated small and diffuse PNH in female fetuses, and demonstrated PNH in two of these. CONCLUSION: PNH is underdiagnosed at prenatal ultrasound, even on targeted scans. Irregular ventricular borders on axial view and irregular square-shaped lateral ventricles on coronal view are suggestive of PNH at prenatal ultrasound.

Prenatal ultrasonographic diagnosis of polymicrogyria.

We report a rare case of polymicrogyria diagnosed at 27 weeks' gestation on ultrasound examination and associated with cytomegalovirus (CMV) infection. The ultrasound finding suggesting this diagnosis was the direct visibility of the overfolded cortical ribbon. The cerebral surface was clearly visible because of a markedly enlarged pericerebral space associated with micrencephaly secondary to CMV infection. Bilateral opercular dysplasia was also present. Very few sonographic markers of infectious fetopathy were observed other than periventricular cysts located behind both ventricular horns. Magnetic resonance imaging (MRI) of the fetal brain confirmed the ultrasound findings and also showed the presence of marked micrencephaly, whereas cephalic measurements acquired on ultrasound examination (biparietal diameter and head circumference) were within the normal range. This case emphasizes the complementary roles of sonography and MRI in the prenatal diagnosis of cerebral abnormalities. Moreover, it illustrates the fact that polymicrogyria is easier to diagnose on ultrasound examination during the second trimester, before the development of secondary sulci.

[Ultrasonography in the management of massive postpartum hemorrhage by Blakemore tube tamponade]. / Apport de l'échographie dans le tamponnement intra-utérin par sonde de Blakemore en cas d'hémorragie grave de la délivrance.

A previous study (2004) evaluated the efficiency and specified the indications of the Blakemore tube tamponade used in the treatment of massive postpartum haemorrhage. During the management of the last case, the insertion of the Blakemore tube was controlled by using ultrasonography. The use of ultrasonography could be helpful to diagnose and explain more quickly the cases of failure, improve the technics by adapting the volume of balloon catheter for optimal tamponade treatment and propose the creation of a new specially designed ovoid balloon catheter.

Use of Sengstaken-Blakemore tube in massive postpartum hemorrhage: a series of 17 cases.

BACKGROUND: To evaluate the efficacy and identify the indications of intrauterine tamponade with a Sengstaken-Blakemore tube in acute postpartum hemorrhage. METHODS: Retrospective study was performed in 17 female patients with massive postpartum hemorrhage despite appropriate medical treatment, and requiring surgery (embolization techniques were not available in our hospital). Patients were treated by inserting a Sengstaken-Blakemore tube in the uterus through the vagina in case of vaginal delivery or through the hysterotomy incision in case of cesarean section. The esophageal balloon was inflated with 250 ml of isotonic saline solution. Patients underwent regional or general anesthesia. A preventive treatment with broad-spectrum antibiotics was systematically administered. RESULTS: Tamponade treatment prevented surgery in 88% of patients, hemorrhage was controlled in 71% of cases (reducing the need for embolization by 80%), and waiting for a transfer for embolization was made possible for 18% of patients. CONCLUSION: Intrauterine tamponade with a Sengstaken-Blakemore tube appears as a simple, low-cost, readily available and effective means of treating life-threatening postpartum hemorrhage. The only apparent contraindication is the discovery of an infection during delivery.

[Medical treatment of ectopic pregnancy: a randomized clinical trial comparing metotrexate-mifepristone and methotrexate-placebo]. / Traitement médical des grossesses extra-utérines: un essai clinique randomisé comparant méthotrexate-mifépristone et placebo-méthotrexate.

BACKGROUND: Medical treatment of ectopic pregnancy is widespread. To increase the efficacy of methotrexate, combination with mifepristone has been proposed. METHODS: We performed a large prospective multicentre double-blind sequential randomized trial in order to compare the efficacy of methotrexate and mifepristone (600 mg given orally) versus methotrexate and placebo. RESULTS: Two hundred twelve ectopic pregnancies were randomized. There was no significant difference in the initial characteristics between the 2 groups. There was no significant difference in the success rate of medical treatment between the methotrexate-mifepristone (n=113) and the methotrexate-placebo group (n=99): 79.6% (90/113) vs 74.2% (72/97) respectively, RR [95% CI]: 1.07 [0.92-1.25], p=0.41. However, there was a quantitative interaction between progesterone level and effect of treatment: when progesterone level was 10 ng/l, the efficacy of the combination of mifepristone and methotrexate was significantly higher than the combination of methotrexate and placebo, with a 83.3% success rate (15/18) vs 38.5% (5/13) respectively. CONCLUSION: Our study failed to demonstrate any benefit of the addition of mifepristone to methotrexate. By contrast, the quantitative interaction between treatment effect and base line serum progesterone suggested that this combination could be reserved to ectopic pregnancies associated with high serum progesterone concentrations.

[Surgical laparoscopy and pregnancy. Eight cases]. / Coelioscopie opératoire et grossesse. A propos de 8 observations.

Eight cases of abdominopelvic surgery including 7 conducted uniquely by laparoscopy point out certain questions concerning diagnosis and management with this technique. These 8 cases included 6 cysts of the ovary, 1 appendectomy and 1 myomectomy. The consequences related to the operation or the anaesthesia and the foetal consequences were evaluated retrospectively. In particular, laparoscopic surgery induces certain pathophysiological modifications which remain to be studied.

[Insulin dependent diabetes and pregnancy: evaluation of the insulin pump]. / Diabète insulino-dépendant et grossesse: évaluation de la pompe à insuline.

OBJECTIVE: To evaluate the effectiveness of continuous insulin infusion (insulin pump) on the materno-foetal morbidity during pregnancy in patients with insulin-dependent diabetes mellitus. METHODS: A retrospective study from 1980 to 1991. SITE. Gynecology-Obstetrics Unit, University of Caen. POPULATION: Eighty-one patients with insulin-dependent diabetes mellitus known to be affected before their pregnancy were followed in the unit from 1980 to 1991. This population was divided into two groups: in the first group, an insulin pump was installed before 15 weeks of amenorrhoea (n = 36) and in the second group, conventional treatment was given with three daily injections of insulin or with a pump installed after 15 weeks of amenorrhoea (n = 45). RESULTS: In the first group with the insulin pump before 15 weeks, there was a higher proportion of severe diabetes, the first consultation occurred earlier, there were half as many cases of neonatal jaundice and the length of hospitalization during the first trimester of pregnancy was longer. There was no difference in Apgar scores, cord pH, birth weight and the proportion of foetal macrosomia, length of the hospitalization in the neonatality ward, rate of malformation, infection, low blood glucose and calcium, transitive respiratory distress and neonatal polycythaemia, length of hospitalization of the mother during the second and third week postpartum, the rate of urinary infection, high blood pressure, hydramnios during pregnancy, delivery route, haemoglobin Alc or fructosamine during pregnancy. There was no perinatal death. CONCLUSION: Although there was no significant difference in the results, which may be explained by the higher number of severe cases of diabetes in the first group, the use of the insulin pump did not appear to improve control of blood glucose levels, and thus to improve the materno-foetal prognosis, except by the bias of earlier attentive management of the pregnancy which led to better outcome.

[The estimation of fetal weight by measurement of the adipose tissue of the extremities. Use in the diagnosis of hypotrophy]. / Estimation du poids foetal par la mesure de la graisse des membres. Application au diagnostic de l'hypotrophie.

OBJECTIVE: To investigate the accuracy of small for age fetuses diagnosis by a new method of fetal weight estimation, in comparison with some others models. A retrospective study. SUBJECTS AND METHODS: From a 232 fetuses population, whom age is known, ultrasound measurement have been performed (BPD, TBD, FL, AC and thigh circumference). Three physicians collaborated to data collection. All measurement have been done within a 3 days duration between measuring and birth in order to compare actual and calculated weight. There are 39 small fetuses coming from 10th percentile (17.5%), between then 24 from 5th percentile. RESULTS: Positive predictive value (PPV) of small for age diagnosis (from 10th P) by our model is 74% with a 74% sensibility and a 94% specificity. With Warsof estimation model, the PPV is only 47% with a 71% sensibility and a 83% specificity (p = 0.001). COMMENTS: Limbs subcutaneous fat ultrasound measurement improve considerably fetal weight estimation quality (mean error = 6% vs 10% for most of the classical models) and, as an extension, small for age fetuses diagnosis. The cutaneous and subcutaneous circumferences, between which is situated fat tissue have a better individual correlation to actual weight than abdominal circumference, usually considered as the best trophicity parameter. CONCLUSION: High positive predictive value show long term predictive detection possibility. It appears that this diagnosis could be done earlier with a better accuracy that the classical ultrasound biometry.

[Cervical ripening : comparison of three methods. Preliminary results of a randomized prospective study]. / Maturations cervicales: comparaison de trois méthodes. Résultats préliminaires d'une étude prospective randomisée.

The authors report the preliminary results of a randomised prospective study begun in April 1992 at the maternity unit of the Caen Regional Hospital group. The aim of the study was to compare the efficacy and tolerability of three methods of cervical ripening in patients at term in whom there was an indication for the induction of labour while local conditions were unfavourable (Bishop score less than 6). In the first group, patients received an intracervical instillation of prostaglandins E2 (Prepidil), in accordance with the usual method of the department. In the patients of the second group, an intracervical Foley catheter with its balloon inflated to 50 cc was inserted and left under traction for 12 hours. Management of patients in the third group consisted of an extraamniotic injection of prostaglandins E2 via a Foley catheter previously inserted into the cervix and the balloon of which was also inflated with 50 cc of sterile water and which was left in place for 12 hours. Regardless of the method, each patient could undergo 3 ripening procedures separated by 24 hour intervals, provided the Bishop score did not reach 6. These results, which concern the first 184 patients enrolled in the protocol show the superior efficacy of the catheter + Prepidil method as compared with the other two (75% success rate after ripening as compared with 50% in each of the other two groups) as well as that intracervical Prepidil is equally effective in terms of success/failure as an intracervical catheter alone.(ABSTRACT TRUNCATED AT 250 WORDS)

[The CHARGE association]. / L'association CHARGE.

The CHARGE association includes a group of several malformations, and always a coloboma and/or choanal atresia. We present 8 cases of this syndrome, 5 complete and 3 incomplete forms. Prognosis at term seems severe, considering the visceral malformations (namely cardiac) and the cerebral handicap often associated. In most cases the CHARGE association is a sporadic event; however, one cannot exclude the possibility that certain forms follow a Mendelian pattern of inheritance. The mechanisms leading to this association have not yet been elucidated: it is probably due to migration abnormalities of the neural crests as in the VATER association of Di George syndrome.