Comparison of two diagnostic tests for gestational diabetes in predicting macrosomia.

OBJECTIVES: To validate a diagnostic test for gestational diabetes which predicts the risk of macrosomia. METHODS: A prospective study was carried out among 354 women at risk for gestational diabetes to compare two glucose tests diagnosing pregnancies at risk of macrosomia. The "practical" test consisted in glucose measurement in the fasting state and two hours after an usual breakfast and the "reference" test was the test proposed in France (O'Sullivan test with or without a 100 g oral glucose tolerance test). Both tests were made between the 24(th) and 28(th) week of gestation. Women at high risk for macrosomia were treated. The first assessment criterion was macrosomia (babies large for gestational age). Because of the presence of women treated for gestational diabetes in our sample, the sensitivity and specificity of the tests in diagnosing pregnancies at risk of macrosomia were calculated using either the incidence of macrosomia observed in our population, or the incidence of macrosomia observed theoretically in the absence of treatment (22% in literature). RESULTS: Macrosomia was diagnosed in 49 neonates (14%). The "practical" test was significantly more sensitive than the reference test (respectively 46.9% versus 16.3%, p=0.0001 in the first case, and 54.3% versus 20.1%, p=0.0001 in the second case). The "reference" test was significantly more specific than the "practical" test (respectively 80% versus 68.2%, p=0.0001 in the first case, and 80.6% versus 70%, p=0.0001 in the second case). CONCLUSION: Our study shows that the simplified "practical" test is more sensitive than the "reference" test currently used in France in screening women at risk of macrosomia.

[Materno-fetal platelet allo-immunization revealed by in utero intracerebral fetal hemorrhage: proposed management for the next pregnancy]. / Allo-immunisation plaquettaire materno-foetale decouverte devant une hémorragie intracérébrale foetale in utero: proposition de prise en charge pour la grossesse suivante.

Materno-fetal platelet allo-immunization causes fetal or neonatal thrombocytopenia and sometimes severe intracerebral bleeding. The HPA-1s antigen is most generally implicated. This accident can occur during the first pregnancy with a major risk of severe recurrence during the next pregnancy. These women require specific care in a specialized center although no consensus has been reached on management of second pregnancies. Proposed treatments include immunoglobulins and/or corticosteroids, fetal blood puncture and unique or iterative platelet transfusions.

Recurrent nonimmune hydrops fetalis: a rare presentation of sialic acid storage disease.

A case of recurrent hydrops fetalis, diagnosed on second trimester's ultrasonography, has led to the diagnosis of sialic acid storage disease. No classic etiology was found after the first accident. The recurrence in subsequent pregnancy raised the possibility of a storage disease that was confirmed by amniocentesis. The diagnosis of Salla's disease was based on high levels of free sialic acid in amniotic fluid and fetal cells culture and by specific histologic features on fetopathologic examination. Diagnosis of inherited diseases is important because it implies a high risk of recurrence which makes mandatory genetic counseling and prenatal care in subsequent pregnancies.

[Eutocic delivery ]. / Accouchement eutocique.

Delivery is uncomplicated in 60 to 75% of cases. Movement through the pelvic pathway requires precise foetal mobility in relation to the pelvis, since the head must pass using a double rotation: 120 degrees deflection around the symphysis pubis and 45 degrees to 135 degrees rotation around the pelvic cavity, according to the presentation. This mechanism, imposed by the adaptation of the form of the pelvis to the upright position, is possible cue to an apparent reduction in volume of the foetal head by its molding and its flexion. This accommodation is favoured by the maturity of the foetal nervous system, the maturity of the uterus, and by the type of presentation. Anterior presentation (anterior left occipito-iliac), more common in multiparas, is usually safer than posterior presentation (posterior right occipito-iliac). more often seen in primiparas.

[Evaluation of the association of a serum marker and second trimester ultrasonography for the screening of trisomy 21 in women of less than 38 years. Prospective study of 5,163 patients]. / Evaluation de l'association marqueur sérique et échographie du deuxième trimestre pour le dépistage de la trisomie 21 chez les femmes de moins de 38 ans. Etude prospective chez 5,163 patientes.

OBJECTIVES: Use of serum markers alone for trisomy 21 screening programs leads to a high rate of amniocentesis. Adding a second parameter (ultrasonography during the second trimester) might reduce this rate yet retain satisfactory sensitivity. This work was conducted to evaluate the pertinence of associating serum hCG level between 16 and 17 weeks gestation and morphological ultrasonography between 18 ans 20 weeks gestation. METHOD: A prospective study was conducted in 5,163 pregnant women aged over 38 years. A morphological ultrasonography was performed in all patients whose hCG level > 1/150 indicated a risk. An amniocentesis was proposed if an anomaly was detected at ultrasonography. RESULTS: Serum hCG was above the risk threshold retained in 11.9% of the patients and among these patients at least one anomaly was detected at ultrasonography in 12%. An amniocentesis was performed in 1.4% of all patients. The positive predictive value of the screening test was 20%. CONCLUSION: Combining a serum marker and ultrasonography during the second trimester allows a reduction in the rate of amniocentesis compared with screening with serum markers alone. Sensitivity for detecting trisomy 21 remains satisfactory.

[Sarcoidosis and pregnancy. A retrospective study of 11 cases]. / Sarcoïdose et grossess. Etude retrospective de 11 cas.

PURPOSE: To analyze the evolutive profile of sarcoidosis together with reciprocal interactions between pregnancy and sarcoidosis. METHODS: All events that occurred during pregnancy in 11 women presenting with sarcoidosis were analyzed. Histological confirmation was obtained for the 11 cases. For all pregnancies were analyzed the course of both sarcoidosis and pregnancy, and the influence of pregnancy on the disease evolution. RESULTS: Among 33 pregnancies, 23 led to the birth of healthy fetuses (five spontaneous abortions, four voluntary abortions, and one therapeutic abortion). The major event was fetal hypotrophy in six cases. Three of them occurred during pregnancy in prednisone-treated patients with active sarcoidosis. No relapse of cured sarcoidosis or further evolution of sarcoidosis that was inactivated as of the beginning of pregnancy were observed. The course of active sarcoidosis varied, as improvement (one case), worsening (two cases) and stabilization (two cases) were observed. During the first year of follow-up after delivery, four relapses and, in two cases, preliminary signs of the disease were observed. CONCLUSION: Apart from the hypothetical but not definite risk of hypotrophy, no negative interaction between sarcoidosis and pregnancy could be established. Pregnancy does not seem to interfere with the course of sarcoidosis. Considering the risk of relapse after delivery, pregnant women presenting with sarcoidosis should benefit from clinical and radiological follow-up.

Outcome of planned pregnancies in systemic lupus erythematosus: a prospective study on 62 pregnancies.

We conducted a prospective study in order to determine planned pregnancy outcome in systemic lupus erythematosus followed in a tertiary referral centre. Pregnancy was authorized if disease was inactive on 20 mg/day prednisone or less for at least 1 yr. Upon the diagnosis of pregnancy, systematic corticosteroids consisting of 10 mg/day prednisone or more were started. In the case of antiphospholipid antibodies, 100 mg/day aspirin was added, replaced by heparin in the pre-partum period. In the case of antiphospholipid syndrome complicated by previous thrombotic events or fetal losses despite aspirin, heparin was prescribed. One woman with a history of atrioventricular block was treated with dexamethasone. Patients were monitored by medical and obstetrical examination, and laboratory tests carried out at least monthly and a quarterly echography. Among 62 pregnancies in 38 women, lupus flare was observed in 27% of the cases, 6% of which occurred in the post-partum period. Flares were moderate except in one renal involvement in a woman with prior diffuse proliferative glomerulonephritis. Therapy was not modified in half of the cases. Pregnancy ended in early spontaneous abortion not related to lupus flare (n = 10), stillbirth (n = 2). induced abortion (n = 2), preterm birth (n = 29) and full-term birth (n = 19). Caesarean section was performed in nine cases. A severe infection occurred in two premature neonates. Another premature neonate was growth retarded. Two children had cutaneous neonatal lupus. No child died, neither had atrioventricular block. Stillbirth and severe prematurity were more common in mothers with antiphospholipid syndrome. After exclusion of early spontaneous and induced abortions, the live birth rate was 96%, that is close to the French general population. The main problem remains a high rate of prematurity, but without maternal or neonatal death.

[Krukenberg tumor during pregnancy with maternal and fetal virilization: a difficult diagnosis. A case report]. / Tumeur de Krukenberg associée à la grossesse avec virilisation maternelle et foetale: un diagnostic difficile. A propos d'un cas.

We present a case of maternal and fetal virilization caused by an androgen-secreting ovarian tumor. Biopsy at caesarean section was required to determine the etiology (Krukenberg tumor) and orient diagnosis to a primary cancer (gastric adenocarcinoma).

Risks of ovulation-induction therapy in systemic lupus erythematosus.

We report on four women with systemic lupus erythematosus who developed two types of complications after ovulation-induction therapy for primary or secondary infertility. Primary infertility was associated with endometriosis in one patient. Three had previously known systemic lupus erythematosus. All had inactive disease at onset of ovulation-induction therapy. Three patients developed symptoms consistent with moderate lupus flare a few weeks after the onset of ovulation-induction therapy. One patient developed inferior vena cava and unilateral left renal vein thrombosis. No patient became pregnant. A high oestrogen level induced by ovulation-induction therapy may explain the occurrence of lupus flare in patients with prior inactive lupus. All our patients had prior asymptomatic antiphospholipid antibodies. One patient developed a major thrombotic event. The presence of antiphospholipid antibodies increases the thrombotic risk related to ovulation-induction therapy. We conclude that ovulation-induction therapy should be restricted to patients with long-standing inactive systemic lupus erythematosus. A preventive increase of the corticosteroid dosage should be proposed in addition to heparin or antiaggregant therapy for those with prior asymptomatic antiphospholipid antibodies, or with heparin therapy for those with prior antiphospholipid antibody-related events.

[Planned pregnancy program in systemic lupus erythematosus]. / Programme de planification de la grossesse au cours du lupus érythémateux disséminé.

OBJECTIVES: Maternal and fetal risk is high during pregnancy for young women with systemic lupus erythematosus. We analyzed outcome after a planned pregnancy program for these patients. METHODS: Between 1982 and 1994, 58 pregnancy were planned in 34 women with systemic lupus. Nine of them had renal and 5 central nervous system involvement; antiphospholipid syndrome was present in 8; steroid therapy was given in 24, immunosuppressors in 2 and plasma exchange in 1. At diagnosis of pregnancy, prednisone was prescribed (at least 10 mg/d), associated with aspirin in all non-symptomatic patients with antiphospholipid antibodies followed by heparin at pre partum. Heparin was used in case of antiphospholipid syndrome. Women with anti-SSA or B antibodies and no past history of congenital atrioventricular block were not given any specific treatment. RESULTS: An acute lupus flare-up occurred in 27% of the cases including 6% in post partum. The flare-up was mild in all cases and treatment had to be changed in half of the cases. There were 9 early abortions, 1 induced abortion for congenital malformation, 2 fetal deaths, 28 premature deliveries and 18 term deliveries. Cesarean section was indicated in 8 cases. Severe neonatal infection occurred in 2 premature infants and 1 other was growth retarded. Cutaneous neonatal lupus was observed in 2 infants. No atrioventricular blocks occurred. CONCLUSION: Fetal death or very premature birth were more frequent in patients with antiphospholipid syndrome. When pregnancy is planned in women with systemic lupus erythematosus, live birth rate reaches 96% after exclusion of early and therapeutic abortions. This rate is close to the rate in the general population. The high rate of premature birth is the main risk, but there were no maternal nor neonatal deaths.

[Vaginal cesarean for fetal deaths in utero]. / Césarienne vaginale dans les morts foetales in utero.

Among a series of 100 cases of retroplacental hematomas we performed vaginal cesareans in 15 and present here the technical difficulties, solutions and indications of this procedure in case of in utero fetal death. Criteria for choosing vaginal cesarean were: term les than 32 weeks, biparietal diameter > 80 mm, fetal weight < 2500 g. The main difficulty was the disproportion between the size of the fetus and the cervical orifice due to insufficient anterior trachelotomy. Possible solutions are posterior trachelotomy or craniotomy. This procedure is rapid and causes little blood loss and important advantage in case of impaired hemostasis.

[In utero study of the eye of normal fetuses. Static ultrasonographic aspects and clinical implications]. / Etude in utero de l'oeil du foetus normal. Aspects échographiques statiques et implications cliniques.

PURPOSE OF THE STUDY: Some ocular diseases are detected by amniotic fluid analysis. However, some serious eye malformations are only detected at birth. By analogy to other organs, we were concerned by fetal sonography studying in utero ocular structures. METHODS: We performed 150 fetal sonograph with 2 abdominal probes and one vaginal probe. We defined: (a) Axes where ocular structures are best visualised, (b) sonographic images of these structures, (c) the date at which these structures are detected. RESULTS: Orbit are detected between 11th and 12th week amenorrhae. Lens are detected between 12th and 14th week. Hyaloid artery appears around the 18th and disappears around the 32nd. Lids were recognised at 16th week. These results were confirmed by similar studies. Pathologic cases described in the literature are discussed. CONCLUSION: Fetal sonography must include a precise study of the eye. However, the eye is a small organ, so its study implicates technically skilled and an experienced practitioner. Fetal sonography gives precise information about normal eye development and allows the detection of structural anomalies (anophthalmos, microphthalmos, cyclopia) or orbital prenatal malformations (hyaloid artery persistance).

[Human papilloma virus infection and renal transplantation. Two personally observed cases and a review of the literature]. / Infection à virus papilloma humain et transplantation rénale. A propos de 2 observations personnelles et d'une revue de la littérature.

Two cases of recurrent genital infection due to human papilloma virus (HPV) infection with preneoplasic lesions were observed in kidney transplant recipients. The neoplasic component appears to be very frequent in this immunosuppressed population with a risk estimated at 7%. According to the different authors in the literature [correction of litterature], genital lesions due to HPV, with or without dysplasia are found in 15 to 30% of the transplant population. The factors of risk are not different from the general population and are a function of sexual activity. The clinical expression of the lesions, their clinical course and recurrence are probably related to the immunosuppressor treatment. All such patients should be carefully screened to allow prevention and treatment, which, as seen in these cases, may be insufficient to irradicate the lesions. New therapeutic approaches should be studied in this group of patients at risk.

How many embryos should be transferred in in vitro fertilization? A prospective randomized study.

OBJECTIVE: To maintain the rate of pregnancy, while suppressing high rank multiple pregnancies by limiting the number of fresh embryos transferred after IVF, in a population selected for potential success. DESIGN: A prospective, randomized study. SETTING: Département de Gynécologie Obstétrique, Centre Hospitalo Universitaire, Paris VI, France. PATIENTS: There were two groups of 28 couples. Women were < or = 35 years of age, with > or = 70% cleavage rate and at least four morphologically regular embryos. INTERVENTION: On the day of ET, either four fresh embryos were transferred (group 1) or two fresh embryos were transferred and two were frozen for later transfer (group 2). MAIN OUTCOME: Pregnancy rate and multiple pregnancy. RESULTS: The pregnancy rate was the same in the two groups with one-third of the high rank pregnancies in group 1 and no pregnancies in group 2. CONCLUSION: Only two fresh embryos need to be transferred in this selected population.