[Vaginal birth after caesarean delivery in twin gestation: is trial of labor allowed?]. / Accouchement par voie basse des grossesses gémellaires sur utérus cicatriciel: peut-on autoriser l'épreuve utérine?

OBJECTIVE: To determine if a trial of labor in twin pregnancy with previous cesarean section is an acceptable alternative to systematic cesarean section. PATIENTS AND METHODS: Based on a retrospective and comparative study from 1st January 1996 to 30th June 2003 in Maternite Jeanne-de-Flandre (Lille) and Pavillon Paul-Gelle (Roubaix), 35 trials of labor in twin pregnancies with previous cesarean section have been compared with 35 twin gestations attempting vaginal delivery without a prior cesarean. This comparative study has been led by sorting out the patients according to their gestational age, parity and maternity. RESULTS: Twenty-seven women (77%) delivered vaginally and eight (23%) by elective caesarean section. Postpartum hemorrhage was more frequent for caesarean section (75%). No scare dehiscence or rupture occurred. There was not any haemostasis hysterectomy or embolisation related to postpartum haemorrhage. Neonatal outcome was similar in both groups. DISCUSSION AND CONCLUSION: Twin trial of labor after a previous cesarean section seems to be a safe alternative to routine repeat cesarean delivery as maternal and fetal morbidity and mortality are safe.

[Massive fetomaternal hemorrhage revealed by decreased perception of active fetal movements]. / Macrotransfusion foeto-maternelle spontanée révélée par une diminution de la perception des mouvements actifs foetaux.

Massive fetomaternal hemorrhage is rare. Without risk factors, early diagnosis is difficult to establish. The clinical and paraclinical manifestations are not specific and depend on fetal compensatory reactions; the Kleihauer test will confirm the diagnosis. Two cases of massive fetomaternal hemorrhage preceded by decreased fetal movements are presented here. An emergency delivery by cesarean section saved one child. Despite a favorable clinical and laboratory evaluation, one fetal death could not be avoided. Early diagnosis and specialised management are essential to improve prognosis. These observations indicate that it is mandatory to carry out a Kleihauer test whenever a decrease of fetal movements is observed.

[Endometrioid adenocarcinoma arising from adenomyosis. A case report and literature review]. / Adénocarcinome endométrioïde résultant de foyers d'adénomyose: à propos d'un cas et revue de la littérature.

In spite of many references to carcinoma arising from endometriosis, there are few documented cases in the literature of endometrioid adenocarcinoma developed in association with adenomyosis. We report a case of endometrioid adenocarcinoma arising from adenomyosis. Carcinogenic and prognostic factors as well as the therapeutic consequences of this unusual situation are discussed. The use of hormonal replacement therapy by patients with a prior history of adenomyosis is also examined.

[Contribution of Doppler ultrasound to the antenatal diagnosis of persistent right umbilical vein: case report]. / Apport des Dopplers couleur et pulsé dans le diagnostic anténatal de la persistance anormale de la veine ombilicale droite: à propos d'un cas.

We report a case of an isolated persistent right umbilical vein which was diagnosed on an ultrasound examination performed in the third trimester of pregnancy. This was made possible by the contribution of color flow Doppler and real-time ultrasound. Having isolated the anomaly no further fetal monitoring was instituted. Delivery was at term and the infant is doing well. Persistent right umbilical vein results from an anomaly of organogenesis. It represents the main intra abdominal anomaly of this vein. Its incidence is estimated at approximately 1 case for 500 antenatal ultrasound examinations. Ultrasonographic diagnosis is relatively easy and can be performed near the end of the first trimester. After insertion in the abdominal wall, the umbilical vein passes round the gallbladder from the right before connecting to the portal vein in the intra-hepatic form; right atrium, inferior vena cava, superior vena cava or iliac vein in extra-hepatic form. Diagnosis is affirmed by color flow Doppler, which emphasizes a continuity of blood flow between the extra and intra abdominal segment of the umbilical vein, and real-time ultrasound, which shows a venous blood flow. Prognosis depends essentially on the existence of congenital malformations, which are observed in 10 to 25% of cases. When isolated, persistent right umbilical vein is generally associated with favorable outcome and must be considered as a normal fetal anatomical variant.

[Placental chorioangiomas diagnosed during the second trimester of pregnancy: four cases]. / Les chorio-angiomes placentaires diagnostiqués au second trimestre de la grossesse.

Placental chorioangioma is a benign vascular tumor found in about 1% of pregnancies at routine histological examination of the placenta. The large placental tumor may cause serious fetal complications. We report 4 cases of placental chorioangioma diagnosed during the second trimester. Three pregnancies with rapidly growing tumors measuring more than 4 cm led to fetal hydrops and perinatal death despite thoracocentesis and cesarean delivery at 33 weeks (1 case) and repeated amniodrainage (1 case). The only surviving infant presented with a 3.3cm tumor which grew progressively to 8 cm at 38 weeks and did not induce polyhydramnios or hydrops. Although aggressive prenatal management of placental chorioangioma has been reported using amniodrainage, intrauterine transfusions, embolization, or ligation of the tumor vessel supply, prognosis remains poor for large tumors and largely depends on fetal hemodynamic tolerance.

[Maternal and congenital syphilis]. / Syphilis maternelle et congénitale.

Testing for syphilis during pregnancy reveals a positive serologic status in 0.02% of cases. However, a 66% rate of stillbirths is noted in women who are infected and who have not benefited from any treatment. Routine screening is at present performed during the early stages of pregnancy but a second serologic test during the third trimester is useful in the diagnosis of a late infection especially in drug users or HIV (human immunodeficiency virus) positive patients. Congenital syphilis is diagnosed in utero when a positive maternal serologic status is associated with ultrasound images showing fetal abnormalities; these include hepatosplenomegaly, hyperechogenic bowel, signs of bowel obstruction or fetal hydrops. Maternal syphilis is treated by delayed action penicillin and is indicated even for patients allergic to the antibiotic which in this particular case is delivered after desensitization. First line therapy by intravenous penicillin is indicated when confronted with the following high risk factors of congenital syphilis: an elevated titre of VDRL (venereal disease research laboratory) at the time of diagnosis or delivery, unknown date of the precise onset of the infection, the appearance of a rash or of a chancre during pregnancy, ultrasound fetal abnormalities or late therapy during the third trimester. Treatment of the new-born child will depend on the results of clinical, serologic and X-ray evaluation. Long term follow-up for at least a year is mandatory.

[Value and limits of complementary investigations in cases of toxoplasmosis seroconversion during pregnancy. A case report and review of the literature]. / Intérêt et limites des investigations complémentaires en cas de séroconversion toxoplasmique en cours de grossesse. A propos d'un cas et revue de la littérature.

We report a case of acute toxoplasmosis during the first trimester of pregnancy in which antenatal diagnosis was negative. Except for non-specific signs of liver failure, assessment by repeated ultrasound scans, testing of fetal blood for toxoplasmic specific antibodies and competitive PCR to isolate the parasite, had ruled out fetal infection. In spite of early treatment with spiramycin, and although the infant was assumed to be non-contaminated, severe hydrocephalus was noted at 3 and half months of life, arising soon after therapy had been stopped. This case focuses attention on the problem of the shortcomings of the diagnostic techniques currently used, and leads us to question our practical course of action. Several questions are thus raised: how reliable are indirect signs of fetal compromise, what is the real sensitivity of the PCR test and how useful are repeated amniocentesis and inoculation of the amniotic fluid to mice.

[Steinert's disease and pregnancy. A case report and recent literature]. / Maladie de Steinert et grossesse. A propos d'un cas et des données récentes de la littérature.

Steinert's disease or myotonic dystrophy is a heredo-degenerative neuroendocrinal dystrophy. It is an autosomal dominant disorder. The arising of a congenital myotonic dystrophy of one of the new-born children of the maternity hospital enabled to diagnose the Steinert's disease of his mother. A review of the international literature enabled us to recall its interactions with pregnancy. There is an aggravation of myotonia and multiple obstetric complications such as miscarriage, premature onset of labor, polyhydramnios, stillbirth, difficulties during the evacuation, atonic postpartum hemorrhage, anesthetic-accidents. The congenital variant of myotonic dystrophy (6 to 30% of the cases) is a severe disease with a high mortality. It is only seen in the offspring of mothers who themselves have myotonic dystrophy. The myotonic dystrophy gene has been isolated and the mutation-causing myotonic dystrophy was found to result from a series of trinucleotide (CTG) repeats located in the 3' untranslated region of the gene. The direct diagnosis is henceforth possible both on the fetus and parents. Steinert's disease and its association with pregnancy are rare, especially when the affected parent has hypogonadism. The diagnosis of the congenital form is difficult because of the mother is unaware of the disorder. Family and personal history may give hints: hydramnios, appearance delay and reduced fetal movements, and the association at birth of generalized hypotonia with neonatal respiratory distress.

[Low transverse laparotomy with rectus abdominus section in gynecology and obstetrics. Apropos of 1,000 cases]. / Laparotomie transversale basse avec section des droits en gynécologie-obstétrique. A propos de 1,000 observations.

The authors report 1,000 cases (357 cesarean sections, 230 hysterectomies for benign lesions, 157 conservative utero-adnexal procedures, 128 tubal plasties, 58 prolapse or incontinence procedures, 70 cancers) ,of laparotomies performed according to the technique described by Mouchel in 1980, i.e. strictly supra-pubic and transverse, from skin to peritoneum, including section of the rectus abdominis. This incision enables to perform in ideal technical conditions, with a minimal complication rate (3 hematomas, 2 incisional hernias for 1,000), and satisfactory esthetic results, almost all of the gynecological and obstetrical surgical procedures (90% of two among the authors' practice). The only contra-indications are, except for cases of previous median laparotomy, ovarian tumors. Neither the high risk of infection, nor obesity, extended hysterectomy, nor fetal distress, represent contra-indications, which is a definite advantage over the Pfannenstiel incision. As compared with the median incision which at some time offered similar results, the esthetics and mainly the strength of the abdominal wall are markedly superior.

[Epidemiological aspects of the foetal alcoholism syndrome. 45 cases (author's transl)]. / Aspects épidémiologiques du syndrome d'alcoolisme foetal. 45 observations en 3 ans.

During a prospective study conducted in Roubaix, 45 neonates presenting with the craniofacial malformation characteristic of the foetal alcohol syndrome were identified over a 3-year period. Twelve had signs of severe alcoholic embryo-foetopathy. This condition, which affects one in 700 neonates, occurs in multiparous women (mean age, 33 years) of low socio-economic status suffering from long standing, complicated alcoholism. Although the mean ethanol blood level may be as high as 1.82 g/l, this substance does not seem to be the only teratogenic agent.

[Endometrial biopsy and hysterography prior to IUD insertion (author's transl)]. / Bipsie d'endometre et hysterographie avant insertion des dispositifs intra-uterins.

PIP: With endometrial biopsy prior to insertion of IUD it is possible to detect about 25% of contraindications, especially endometritis, which is often present without any signs of genital infection. After observations on 290 patients the authors found that hysterosalpingography would still show anomalies gone undetected by normal biopsy. Such abnormalities as hydrosalpinx, cervical carcinoma, and uterine anomalies constitute definite contraindication to the use of IUD. After such assessment the authors were able to improve IUD retention on 280 insertions, obtaining a retention rate of 87% after 1 year of use. (Summary in ENG).^ieng

[A study of gamma-glutamyl-transpeptidase and of the ratio of IgA to transferrin in the pregnant woman (and when using oral contraception) and in the newborn (author's transl)]. / Etude de la gamma-glutamyl-transpeptidase et du rapport IgA sur transferrine chez la femme enceinte (et sous contraception orale) et le nouveau-né.

The authors confirm the absence of a marked variation in levels of gamma-glutamyl-transpeptidase in women under the influence of oestrogens, but a considerable rise in this enzyme in the newborn, particularly after delivery following vaginal obstetrical manoeuvre. They base these findings on 242 samples taken from pregnant women in the 3 trimesters of normal pregnancies and after delivery, and in the cord blood of newborn infants as well as in patients taking oral contraception. There is a slight rise in the levels of immunoglobulins A in the 3rd trimester of pregnancy. The overall rise in the blood levels of transferrin under the effect of oestrogens is confirmed. Norms were obtained for the levels of the IgA/T ratio which drops progressively as pregnancy progresses and with oral contraception. It has been found that in the last two trimesters the upper limit of the normal is 1 for the IgA/T ratio as compared with 1.9 in the general population. The study of these constants is of value when screening for maternal alcoholism and as a consequence for the prevention of the fetal alcohol syndrome.

[The effect of amniofetography on the fetal thyroid (author's transl)]. / Incidence de l'amniofoetographie sur la thyroïde foetale.

Although there are certain advantages of amniofetography they must be considered against the risk of fetal hypothyroidism "in utero" with its prognostic danger. The authors report six case histories which illustrate this risk and they draw attention to the possible effect on the thyroid gland "in utero". Amniofetography should therefore be reserved solely for those cases in which the indications exist and there are no other possible means of diagnosis. If it is indicated means must be found of treating the possible transitory iatrogenic hypothyroidism.

[Danger of iodine drugs in the pregnant woman]. / Dangers des médicaments iodés chez la femme enceinte.

The authors draw attention to the fact that the possible effects of drugs containing iodine are often neglected during pregnancy. As an example, they report the following observation : "A young woman with benign asthma, treated for 14 years Asthmasedine and Asthmaligne, gave birth, on the 36th week of pregnancy, to a child apparenty dead but who was able to be reanimated. The child showed two types of signs : respiratory distress due to higher neurological disorders and a multinodular, non-compressing goiter. These two complications were caused by a congenital hypothyroidism corroborated by laboratory tests and due to the prolonged absorption of iodinated drugs by the mother". In conclusion, in cases of women receiving during pregnancy high doses of drugs containing iodine (250 such drugs are recorded in the Vidal), it is desirable to control the effect on the fetus and to propose an intra-amniotic therapy with L-Thyroxine, thus allowing a cerebral development close to normal.