[Pathophysiology of preeclampsia: some recent data]. / Physiopathologie des prééclampsies : quelques données récentes.

Placental ischemia is the background of the pathophysiology of preeclampsia. It is mainly - but not exclusively - caused by an immunological conflict between maternal NK cells of the decidua and of the uterine junctional zone, and the HLA-C antigens shared by interstitial trophoblast. The maternal disease is the consequence of the placental ischemia, and is characterized by an inflammatory syndrome with an oxidative stress and an endothelial cell dysfunction. Genetics play an essential part in each of these steps.

[Postpartum urinary retention]. / Rétention vésicale du post-partum.

Postpartum urinary retention is an uncommon event that occurs in 0.7 to 0.9% of vaginal deliveries. An ignorance of this situation can lead to delayed diagnosis worsening the prognosis and to inadequate treatments. This complication is defined as the absence of spontaneous micturition within 6hours of vaginal delivery with a bladder volume above 400mL. The etiology depends on multiple factors. Because of physiological changes during pregnancy, the bladder is hypotonic with an increased post-void residual volume. The occurrence of a perineal neuropathy during delivery may cause a urinary retention. Risk factors are primiparity, prolonged labour, instrumental delivery and perineal lacerations. Treatment consists on clean intermittent catheterization and recovery occurs generally in 72hours. Persistent urinary retention is the principal short-term complication and should be treated by clean intermittent self-catheterization. Long-term consequences are poorly reported in the literature.

[Fetal-pelvic disproportion and X-ray pelvimetry]. / Disproportion foeto-pelvienne et radiopelvimétrie.

OBJECTIVES: X-ray pelvimetry is a method that not only allows exploring the pelvic inlet but also would partially explain the "fetal-pelvic disproportion". The aims of this study are to estimate this capacity to actually explain the aforementioned disproportion, assessing as well its influence on the follow-up of later pregnancies. PATIENTS AND METHODS: A retrospective study was performed in Angers' hospital, France. We went back over 11 years and included 90 nulliparous patients, all of whom had a C-section due to "fetal-pelvic disproportion". We defined a specific sub-group for arrest of labor. RESULTS: Only 55.5% of the patients had an unfavorable Magnin's index (<23 cm) and 47.8% were, according to it, in the uncertainty - or dystocia - zone. Labor arrest was explained by mechanical obstruction (72% of the patients had pelvic abnormalities) and by dysfunctional patterns (40% due to a posterior position of the occiput, 18% because of hypotonic labor). An important number of elective C-sections (55 cases) was recorded for subsequent pregnancies. Reasons were bound to X-ray pelvimetry (35 cases), the patients' wish (two cases), to maternal pathology (four cases), to a hydramnios (three cases) and to the suspicion of fetal distress (five cases). DISCUSSION AND CONCLUSIONS: The term "fetal-pelvic disproportion" should be carefully used. Some authors used it in case of arrest of labor during two hours, a normal dynamic pattern, sufficient cervical dilation and, for many, an occipoanterior position.

Perineal infiltration with lidocaine 1%, ropivacaine 0.75%, or placebo for episiotomy repair in parturients who received epidural labor analgesia: a double-blind randomized study.

BACKGROUND: Episiotomies are performed in approximately 20% of vaginal deliveries and may result in postpartum pain. Perineal infiltration with lidocaine during the episiotomy is widely used, despite an early study showing no difference when compared with saline. Ropivacaine has increasingly been used in the obstetric setting, although not for episiotomies. We sought to compare the analgesic efficacy of ropivacaine, lidocaine or saline for perineal infiltration before repair of a mediolateral episiotomy in patients who delivered with epidural labor analgesia. METHODS: In this double-blind randomized prospective study, infiltration with 15 mL of 0.75% ropivacaine, 1% lidocaine, or saline was performed immediately before initiating the perineal repair. During the first 24 h, the time to the first oral analgesic, analgesic intake, visual analog scale scores for pain, and patient satisfaction scores were recorded. RESULTS: A total of 154 patients were included. Demographic data were comparable between the groups. Time to first oral analgesic request was 13.9h with 0.75% ropivacaine, 17.0 h with 1% lidocaine, and 16.6 h with saline (P=0.104); the proportion of patients who did not request oral analgesics were 35%, 54% and 53%, respectively (P=0.09). Visual analog pain scores were low and not different between the three groups (ropivacaine 16.8+/-11.6, lidocaine 12.4+/-9.7; and saline 16.2+/-11.5, P=0.08). CONCLUSION: For the first 24 h, perineal infiltration of ropivacaine, lidocaine, and saline were equivalent in producing post-episiotomy analgesia.

[Very premature births: Dilemmas and management. Part 1. Outcome of infants born before 28 weeks of postmenstrual age, and definition of a gray zone]. / Naissances très prématurées : dilemmes et propositions de prise en charge. Première partie : pronostic des naissances avant 28 semaines, identification d'une zone grise.

With very preterm deliveries, the decision to institute intensive care, or, alternatively, to start palliative care and let the baby die, is extremely difficult, and involves complex ethical issues. The introduction of intensive care may result in long-term survival of many infants without severe disabilities, but it may also result in the survival of severely disabled infants. Conversely, the decision to withhold resuscitation and/or intensive care at birth, which is an option at the margin of viability, implies allowing babies to die, although some of them would have developed normally if they had received resuscitation and/or intensive care. Withholding intensive care at birth does not mean withholding care but rather providing palliative care to prevent pain and suffering during the time period preceding death. The likelihood of survival without significant disabilities decreases as gestational age at birth decreases. In addition to gestational age, other factors greatly influence the prognosis. Indeed, for a given gestational age, higher birth weight, singleton birth, female sex, exposure to prenatal corticosteroids, and birth in a tertiary center are favorable factors. Considering gestational age, there is a gray zone that corresponds to major prognostic uncertainty and therefore to a major problem in making a "good" decision. In France today, the gray zone corresponds to deliveries at 24 and 25 weeks of postmenstrual age. In general, babies born above the gray zone (26 weeks of postmenstrual age and later) should receive resuscitation and/or full intensive care. Below 24 weeks, palliative care is the only option offered in France at the present time. Decisions within the gray zone will be addressed in the 2nd part of this work.

[Very premature births: Dilemmas and management. Second part: Ethical aspects and recommendations]. / Naissances très prématurées : dilemmes et propositions de prise en charge. Seconde partie : enjeux éthiques, principes de prise en charge et recommandations.

In the first part of this work, the outcome following very premature birth was assessed. This enabled a gray zone to be defined, with inherent major prognostic uncertainty. In France today, the gray zone corresponds to deliveries occurring at 24 and 25 weeks of postmenstrual age. The management of births occurring below and above the gray zone was described. Withholding intensive care at birth for babies born below or within the gray zone does not mean withholding care but rather providing palliative care to prevent pain and suffering during the time period preceding death. Given the high level of uncertainty, making good decisions within the gray zone is problematic. Decisions should be based on the infant's best interests. Decisions should be reached with the parents, who are entitled to receive clear and comprehensive information. Possible decisions to withhold intensive care should be made following the procedures described in the French law of April 2005. Guidelines, based on gestational age and the other prognostic elements, are proposed to the parents before birth. They are applied in an individualized fashion, in order to take into account the individual features of each case. At 25 weeks, resuscitation and/or full intensive care are usually proposed, unless unfavorable factors, such as severe growth restriction, are associated. A senior neonatologist will attend the delivery and will make decisions based on both the baby's condition at birth and the parents' wishes. At 24 weeks, in the absence of unfavorable associated factors, the parents' wishes should be followed in deciding between initiating full intensive care or palliative care. Below 24 weeks, palliative care is the only option to be offered in France at the present time.

[Pregnant women and smoking: descriptive study and prognostic factors to stop smoking during pregnancy]. / Le tabagisme gravidique. Etude descriptive et facteurs pronostiques d'arrêt du tabac pendant la grossesse.

UNLABELLED: Nicotine addiction (NA) is a serious public health problem. Today, smoking effects on the foetus and the mother are well known; however, studies into smoker's behaviour are lacking. The aim of our paper was to identify factors which influence either NA stopping or continuation during pregnancy. METHODS: It's a descriptive study, using a questionnaire, among pregnant women during prenatal consultation in a university hospital, at home with freelance mid-wives or in mother and infant welfare services (PMI). RESULTS: Two hundred and forty-one questionnaires were analysed. Smoker's behaviour, psycho-environmental factors, co-addictions, were described and compared. One out of four women was smoking during pregnancy and one out of ten was smoking more than 10cigarettes per day. One out of three women who were smokers before pregnancy, stated that they had stopped NA during the year. Only 58/241 readings of exhaled carbon monoxide were performed, which reflects hesitation of medical staff to employ this device. Forty seven women indicated the number of alcohol glasses consumed during pregnancy. The study showed that partner's attitude towards smoking, good or bad mood during pregnancy, number of cigarettes smoked before pregnancy and medical information would appear to be significant factors that influence NA stopping during pregnancy. CONCLUSION: The identification of prognostic factors for NA stopping is of primordial importance, especially among heavy smokers, in order to target the actions necessary to help NA stopping.

[Two observations of evisceration after caesarean section performed according the so-called Stark procedure]. / A propos de deux observations d'éviscération après césariennes réalisées selon la technique de Stark.

Two cases of evisceration after caesarean sections performed according the Misgav Ladach General Hospital procedure (Stark's procedure) are reported. In these cases, omentum was sutured between the edges of fascia recti, creating a weakness of the abdominal sheath. These cases claim about a strict procedure for fascia suture. Also, these cases question about the parietal peritoneal closure and the drawing of rectus muscles, which are vertical breaks; so, these sutures close transversal incision of the abdominal wall with cross sutures, which are very secure.

[Indications and prerequisites for operative vaginal delivery: when, how and where?]. / Indications et prérequis à la réalisation d'une extraction instrumentale : quand, comment et où ?

OBJECTIVE: To determine the indications and prerequisites for operative vaginal delivery. METHODS: Articles were searched using PubMed and Cochrane library. RESULTS: Indications for operative vaginal delivery are non-reassuring fetal status (NP4), no progress from 30minutes of adequate active pushing, maternal exhaustion (NP5), or medical indications to avoid Valsalva (NP5). Operative vaginal delivery (Thierry's spatulas, forceps, and vacuum delivery) before that cervix is fully dilated and fetal head is fully engaged is not recommended (NP4). Obstetricians have to know patient medical record and the fetal head position before performing operative vaginal delivery (NP5). The reliability of transvaginal examination to determine the fetal engagement and intrapartum fetal head position is 88% and 80% respectively (NP2). Transabdominal ultrasound assessment is recommended in cases of doubts about the fetal head position (NP5). Available data are not sufficient to fully contraindicated midpelvic operative delivery. Each case should be considered individually and depending on the skill of the obstetrician (NP5). Obstetricians should be aware that they may wrongly consider the fetus engaged in the midpelvis in 6% of cases, whereas it is not really engaged. Moreover, the presence of factors predictive of failed operative vaginal delivery must contraindicated midpelvic operative vaginal delivery and indicated a cesarean delivery (NP5). In general, midpelvic operative vaginal delivery is not recommended. Routine instrumental delivery in theatre and episiotomy for operative vaginal delivery are not recommended (NP3 and NP4, respectively). CONCLUSIONS: Recommendations for operative vaginal delivery should be respected to minimize both fetal and maternal trauma. Obstetricians should anticipate the complications that may occurred following operative vaginal delivery.

[Information in perinatal medicine: ethical aspects]. / L'information dans le contexte du soin périnatal: aspects éthiques.

Besides the undeniable need to respect parental autonomy, providing information is a legal and moral obligation, to be informed a basic right. The act of informing should be considered as an exchange and necessarily begins by listening to the other. According to the jurisprudence of the Court of Cassation that draws on Article 35 of the Deontological Code, information has to be clear (implying an educational effort, availability and to check that the information has been well understood), appropriate (adapted to each situation and person) and honest (which supposes a moral contract between parents and physicians). Loyalty implies a consideration of the uncertainty underlying medical practice, and of the limitations in arriving at a prognosis. Indeed, caution needs to be exercised in conveying information, taking into account the risk of its becoming self-fulfilling, which could modify the way in which parents take care of their child. The information given has to be coherent, both within the spatial dimension (coherence of information between the different maternity services in the perinatal network) and the temporal dimension (coherence of information between pre- and postnatal stages). It must be acknowledged that information is essentially subjective. There is a fundamental difference between coherence and uniformity, and as regards information, uniformity is neither possible nor desirable. In each situation, priority must be given to oral information delivered in an appropriate material context. The principle of establishing, in the medical file, a written trace of the information given at various stages is one way to guarantee its coherence.

[Postpartum contraception: medical guidelines, women's point of view]. / La contraception du post-partum: les recommandations médicales, le point de vue des femmes.

PURPOSE: Postpartum contraception is subjected to specific medical guidelines related to the suckling mode. The practitioner must conciliate prescription rules with women's expectations. The purpose of this work was to estimate the medical practice in the maternity centre at a local hospital and the actual practice of women at home, in immediate postpartum and during the year that followed the childbirth. METHOD: One hundred and four new mothers from the maternity centre, in September 2004, took the survey. During their stay after birth, they filled a questionnaire on contraception. Various data have been collected from their obstetrical file. The analysis allowed the synthesis of medical guidelines on postpartum contraception. One year later, patients answered a telephone survey about their contraceptive practice. RESULTS: In our survey, two-third of the new mothers (61.5%) chose breast-feeding. Seventy percent of them received progestins as contraceptives. Three out of four women (78%) followed this prescription after they left the hospital. Two-third (62.5%) of the women who had chosen artificial suckling received a prescription of estroprogestin. The majority of them (96%) used it after their return home. A high number of women (87.5%) estimated that these contraceptions were efficient, but more than a third of them thought they were uneasy to use (38.9%). Half of the women (52.8%) forgot their contraception during postpartum and the majority of them (86%) changed it within a year. A quarter (23.1%) of the contraception follow-up during this time was made by a general practitioner. CONCLUSION: The practice in the maternity centre generally follows medical guidelines. However, it seems important to adapt postpartum contraception to the real practice of women. The general practitioner plays a major role in this management, especially during well-baby visits.

[The fundal height measurements in single pregnancies and the detection of fetal growth retardation]. / La mesure de la hauteur utérine dans les grossesses uniques et le dépistage des retards de croissance intra-utérins.

Symphysis fundus measurements are a reliable mean for screening of fetal growth retardation. The techniques of the measurements, the curves of normality, and the efficiency of this method are discussed. A single formula is put forward to identify the patients witch can profit by extra ultrasound examinations and special clinical surveillance. In France, ultrasound examinations are scheduled at 22 and 32 weeks. Between 22 and 32 weeks, and after 32 weeks, symphysis fundus measurements are needed to suspect intra uterine fetal retardation, and, following suspicion, a new ultrasound examination is helpful.