Prophylactic intrapartum amnioinfusion: a controlled retrospective study of 135 cases.

OBJECTIVE: To show that intrapartum prophylactic amnioinfusion (AI) in case of oligohydramnios or particulate meconium-stained amniotic fluid could be beneficial. STUDY DESIGN: From the first March 1993 until the 30th June 1995, 4031 women were delivered at the University Hospital of Poitiers. Patients presenting with oligohydramnios (G1) (71 patients with an amniotic fluid index below 5 cm) or a particulate meconium-stained amniotic fluid (G2) (64 patients) were included. Each group was compared to an historical control group constituted retrospectively according to the following criteria: oligohydramnios (CG1), particulate meconium-stained amniotic fluid (CG2), age, parity, gestational age and duration of labor. Statistical analysis was performed using the Student's t-test and the Fisher's exact test when appropriate with a level of significance of P less than 0.05. RESULTS: The mean infused volume was 893 ml in G1 and 734 ml in G2. A significant difference was found in terms of cesarean section between G1 and CG1 (11.3 vs. 24.5%; P < 0.05) and of assisted deliveries for fetal distress between G2 and CG2 (12.5 vs. 23.43%; P < 0.05). No other significant difference was found between the study groups and their control for all other studied criteria. When considering more specifically the presence of meconium below the vocal cords we also could not find any significant difference between G2 and CG2 (1.6 vs. 9.4%; P = 0.05). No neonatal or maternal adverse effect happened in this short study. COMMENT: AI is easy to perform during labour in case of oligohydramnios or particulate meconium-stained amniotic fluid. In case of oligohydramnios, a decreased rate of cesarean sections has been observed in the infused group. Considering patients with particulate meconium-stained amniotic fluid, less interventions for fetal distress and neonates with meconium below the vocal cords has been found in the infused group. Further prospective evaluation is needed to confirm these results in case of particulate meconium-stained amniotic fluid and to compare the advantage of prophylactic versus therapeutic AI performed in case of oligohydramnios and abnormal fetal heart rate.

[Cervical maturation by repeated applications of prostaglandin E2 gel. 186 cases]. / Maturation cervicale par applications itératives de gel de prostaglandines E2. A propos de 186 cas.

OBJECTIVE: A prospective clinical trial of cervical ripening with intracervical prostaglandin E2 gel in repeated administrations was performed. STUDY DESIGN: One hundred eighty-six patients were enrolled in this prospective trial between 01/01/89 and 31/12/93. these patients with unripe cervix (Bishop score < 5) required induction of labor because of pregnancy disorders. Mean patient age was 28.2 years (range 15 to 43), mean gestational age was 39.2 week's gestation (range 33 to 43) and mean parity was 1.8 (range 1 to 10). Our exclusion criterias were as follow: twin pregnancies, breech presentation and premature rupture of membranes. A 0.5 mg prostaglandin E2 gel was administered into the cervix every four hours maximal of three doses before induction of labor with oxytocin. Maternal and neonatal results were reviewed. RESULTS: Patients required a single dose of gel in 19.9% of cases, two doses in 26.3% and three doses in 53.8%. Induced labor during cervical ripening occurred in 55.4% of patients. A cesarean section was necessary in 22% of cases. This rate was both significantly related to the initial Bishop score and to the Bishop score at the end of the procedure. Patient with induced labor during the cervical ripening had a significantly lower cesarean section rate compared to these who needed induction with oxytocin (10.7% versus 33.8%; p < 0.01). The uterine hyperstimulation rate was 1.6%. A 1 min Apgar score less than 7 occurred in 1.1% of neonates. COMMENTS: Our results do not demonstrate benefit of repeated administration comparison to a single administration described in literature. Maternal and neonatal morbidity is low in this study but cervical ripening should be used only when pregnancy disorders require prompt delivery within twenty-four hours.

[Prophylactic amnion infusion during labor. Apropos of 195 cases]. / L'amnio-infusion prophylactique au cours du travail. A propos de 195 cas.

OBJECTIVE: To show that intrapartum prophylactic amnioinfusion in case of oligohydramnios or particulate meconium-stained amniotic fluid could be beneficial. STUDY DESIGN: From March 1st, 1993 until December 31st, 1996, 6845 women were delivered at the University Hospital of Poitiers. Patients presenting with oligohydramnios (G1) (118 patients with an amniotic fluid index below 5 cm) or a particulate meconium-stained amniotic fluid (G2)(77 patients) were included. Each group was compared with a historical control group constituted retrospectively according to the following criteria: oligohydramnios (CG1), particulate meconium-stained amniotic fluid (CG2)), age, parity, gestational age, and duration of labor. Statistical analysis was performed using the Student's t test and the Fisher's exact test when appropriate with a level of significance of p < 0.05. RESULTS: The mean infused volume was 883 ml in G1 and 751 ml in G2. A significant difference was found in terms of cesarean section between G1 and CG1 (14% versus 25%, p < 0.05) and of assisted deliveries for fetal distress between G2 and CG2 (5% versus 18%, p < 0.02). No other significant difference was found between the study groups and their control for all other studied criteria. When considering more specifically the presence of meconium below the vocal cords we also find a difference between G2 and CG2 (5% versus 14%) which was not significant. No neonatal or maternal adverse effects happened in this short study. COMMENT: Amnioinfusion is easy to perform during labor in case of oligohydramnios or particulate meconium-stained amniotic fluid. In case of oligohydramnios, a decreased rate of cesarean sections has been observed in the infused group. Considering patients with particulate meconium-stained amniotic fluid, less interventions for fetal distress and neonates with meconium below the vocal cords has been found in the infused group. Further prospective evaluation is needed to confirm these results in case of particulate meconium-stained amniotic fluid and to compare the advantage of prophylactic versus therapeutic amnioinfusion performed in case of oligohydramnios and abnormal fetal heart rate.

[Biological diagnosis of premature rupture of membranes: respective values of diamine oxidase activity compared to vaginal fluid pH (Amnicator)]. / Diagnostic biologique de la rupture prématurée des membranes: valeurs respectives du test à la DAO et de la mesure du pH vaginal (Amnicator).

OBJECTIVES: To compare the sensitivity (Se), specificity (Spe), positive predictive (PPV) and negative predictive (PNV) values of 2 tests used routinely for suspected premature rupture of the membranes (PROM) and their implication in the management of such cases. PATIENTS AND METHODS: From 1 November 1995 to 31 July 1996, 87 patients: 16 with obvious PROM on physical examination (group I) and 71 with suspected PROM (group II) were tested with both DAO and Amnicator. PROM was arbitrary confirmed in group II when delivery occurred within 48 hours after the diagnosis was suspected. The corrected chi 2 test was used to compare both tests results in group II. RESULTS: In case of obvious PROM, the sensitivity of the DAO and Amnicator tests were 75 and 87.5% respectively. Eleven patients from group II delivered within 48 hours following admission and the 2 tests results were respectively: Se 90.9 and 81.81%, Spe 100 and 83.33%, PPV 100 and 52.63% and PNV 98.36 and 96.15%. DAO gave better results in terms of Spe and PPV (p < 0.05). COMMENTS: The DAO test remains a reference test when PROM is suspected but when it is not available (during night or week-end), the quite good negative predictive value of Amnicator could avoid unnecessary hospitalisation and permit later DAO test.

[Lesions of the hand and upper limb in children with linear scleroderma. Therapeutic approach in two cases]. / Lésions de la main et due membre suprieur dans les schlérodermies en bande de l'enfant. Approche thérapeutique a propos de deux cas.

The authors report two cases of linear scleroderma (LS) in children, located on the hand and upper limb. LS is rare in children (245 cases reported in the literature). LS initially consists of a sclero-inflammatory lesion, followed by a sclero-atrophic lesion, characterized by its linear arrangement selective involvement of one limb, and its local and regional effects. The onset is generally marked by development of a sclerodermic line, sometimes associated with extra-cutaneous lesions. The active phase of the disease is long (mean: 3 years), with multiplication or extension of the initial lesions (frontal "coup de sabre", hemiatrophy). Systemic complications are rare (Raynaud's phenomenon, glomerulonephritis...). Regional complications (retractile myositis, articular stiffness, shortening) are frequent, severe and persistent (75% of cases). Treatment has not been definitively standardized, but should include:--systemic corticosteroids, quite active in early forms. --physiotherapy and external prostheses during the early and active phase, and finally surgical correction of orthopaedic sequelae. They are often difficult operations, with partial results, but functionally very useful, especially with the addition of cutaneous expansion. Our 2 cases demonstrate the considerable functional improvement achieved in the hand.

[Transabdominal amnio-infusion facilitates external version maneuver after initial failure. Six successful attempts]. / L'amnio-infusion transabdominale facilite la version par manoeuvre externe après échec préalable de celle-ci. A propos de 6 réussites.

External version was successful after initial failure in 6 cases after transabdominal amnio-infusion. Filling the uterine cavity by amnio-infusion with 700 to 900 ml saline solution at 37 degrees C facilitated cephalic presentation in these 6 cases. In each case, a prior version attempt had been unsuccessful. Amnio-infusion was performed under continuous sonographic monitoring before a second attempt the next day. The clinical situation was different in the 6 cases which all terminated by normal cephalic delivery. Two patients were first parity, another has a single uterine scar, 3 had a normal pelvis (Magnin > 23), one a narrow pelvis (Magnin = 22.7) and 2 had a pelvis considered pathological (Magnin < 22). The main goal of this preliminary study was to evaluate the feasibility and safety of this new indication for transabdominal amnio-infusion. This new indication should be evaluated by several clinical trials, but it would new appear reasonable to propose transabdominal amnio-infusion in patients with a pathological pelvis and/or a single cicatricial uterus.

[Ovarian hyperstimulation syndrome and thrombosis. Apropos of a case of thrombosis of the internal jugular vein. Review of the literature]. / Syndrome d'hyperstimulation ovarienne et thrombose. A propos d'un cas de thrombose de la veine jugulaire interne. Revue de la littérature.

Thrombosis of the internal jugular vein was associated with a severe syndrome of ovarian hyperstimulation. After in vitro fertilization, a twin pregnancy was obtained in a 31-year-old patient with severe endometriosis. On the day of follicle collection, plasma oestradiol was 3050 mg/ml. Ten ovocytes were collected and 3 embryos were implanted. A syndrome of severe ovarian hyperstimulation (ascites, pleural effusion) developed 3 weeks later and symptomatic treatment was given. Phlebitis of the upper left limb was diagnosed at 9 weeks amenorrhoea and echo-Doppler confirmed the diagnosis of subclavian and internal jugular venous thrombosis. Search for a cause was negative excepting a frank drop in protein S activity to 35%. Post-partum assay and assay in family members confirmed that the deficiency was acquired during pregnancy. The clinical course was favourable with anticoagulant therapy (heparin, then low-molecular weight heparin). Intra-uterine death of one of the fetuses occurred at 21 weeks amenorrhoea and a 2,550 g girl was born by vaginal delivery at 36 weeks. The Apgar score at birth was 10/10. In a review of the literature on vascular events in fertilization, programmes showed that severe syndromes of ovarian hyperstimulation, endogenous hyperestrogenism, multiple pregnancy and predominance of upper limb are the most frequently observed criteria. We emphasize the importance of preventing these thromboembolic events with subcutaneous heparin during the first trimester of pregnancy followed by low-molecular weight heparin, particularly in patients with a history of thromboembolism and/or patients with severe ovarian hyperstimulation.

[Premature rupture of membranes. Prospective study of 218 cases]. / La rupture prématurée des membranes. Etude prospective de 218 observations.

OBJECTIVES: To verify the importance of a wait-and-see attitude after premature rupture of the membranes before 34 weeks of amenorrhoea when allowed by the initial physical examination and of an intervening attitude after 34 weeks. STUDY: A prospective study included 218 cases of premature ruptures of the membranes divided into four groups according to the weeks of amenorrhoea: Group 1, before 32 weeks (n = 11); Group 2, between 32 and 34 weeks (n = 26); Group 3, between 34 and 37 weeks (n = 18); Group 4 after 37 weeks (n = 163). RESULTS: Before 34 weeks of amenorrhoea, the frequency of premature rupture of the membranes was 0.72%, of germ-positive infants 8% and of infected infants, 11%. Perinatal mortality was 80% and 17.4% of the infants were delivered by cesarian section. Labour was induced in 100 cases (46%), when there was evidence of infection, after a 24-hour waiting period or at 34 weeks of amenorrhoea. When the aspect of the cervix was unfavourable, cervical maturation was induced by intravenous injection of prostaglandins in 75 cases (34%). CONCLUSION: When the rupture occurred before 34 weeks of amenorrhoea and without signs of infection, tocolysis should be entertained. From 28 to 34 weeks and when a favourable outcome is expected, maturation by corticoids can be proposed. When chorio-amniotic infection is suspected and is not confirmed by the laboratory, antibiotic prophylaxy does not appear to improve fetal outcome. The beneficial effect of a conservative wait-and-see attitude before 34 weeks and of intervening thereafter can only be demonstrated with a large randomized study. Thus each case must be managed individually, making it difficult to establish a standard recommended attitude.

[Benign pelvic schwannoma. A case report]. / Le schwannome bénin pelvien. A propos d'un cas.

A rare case of benin pelvic schwannoma was observed fortuitously during normal echographic follow-up of a cyst of the ovary. The usually silent tumours are difficult to diagnose. Computed tomography appears to be the most informative examination concerning the nature of these tumours and their relations with the surrounding structures. Nevertheless, the exact nature cannot be determined before curative surgical exeresis and pathology examination. The risk of relapse is extremely small, but does exist, justifying follow-up.

[Obstructive myocardiopathy and pregnancy]. / Myocardiopathie obstructive et grossesse.

We report a case of pregnancy in a patient with severe obstructive cardiomyopathy treated with beta-blockers. A review of the literature shows that in spite of possible worsening of the functional symptomatology, pregnancy does not increase the risk of mortality. The recommendations for the conduct of the delivery are reviewed. The risks for the fetus are essentially linked to the treatment with beta-blockers and the possibility of inheritance of the condition.