Intrauterine growth restriction is associated with structural alterations in human umbilical cord and decreased nitric oxide-induced relaxation of umbilical vein.

INTRODUCTION: Intrauterine growth restriction (IUGR) affects ∼8% of all pregnancies and is associated with major perinatal mortality and morbidity, and with an increased risk to develop cardiovascular diseases in adulthood. Despite identification of several risk factors, the mechanisms implicated in the development of IUGR remain poorly understood. In case of placental insufficiency, reduced delivery of oxygen and/or nutrients to the fetus could be associated with alterations in the umbilical circulation, contributing further to the impairment of maternal-fetal exchanges. We compared the structural and functional properties of umbilical cords from growth-restricted and appropriate for gestational age (AGA) term newborns, with particular attention to the umbilical vein (UV). METHODS: Human umbilical cords were collected at delivery. Morphological changes were investigated by histomorphometry, and UV's reactivity by pharmacological studies. RESULTS: Growth-restricted newborns displayed significantly lower growth parameters, placental weight and umbilical cord diameter than AGA controls. Total cross-section and smooth muscle areas were significantly smaller in UV of growth-restricted neonates than in controls. Maximal vasoconstriction achieved in isolated UV was lower in growth-restricted boys than in controls, whereas nitric oxide-induced relaxation was significantly reduced in UV of growth-restricted girls compared to controls. CONCLUSION: IUGR is associated with structural alterations of the UV in both genders, and with a decreased nitric oxide-induced relaxation in UV of newborn girls, whereas boys display impaired vasoconstriction. Further investigations will allow to better understand the regulation of umbilical circulation in growth-restricted neonates, which could contribute to devise potential novel therapeutic strategies to prevent or limit the development of IUGR.

Inexperienced sonographers can successfully visualize and assess a three-dimensional image of the fetal face using a standardized ultrasound protocol.

INTRODUCTION: A standardized three-dimensional ultrasonographic (3DUS) protocol is described that allows fetal face reconstruction. Ability to identify cleft lip with 3DUS using this protocol was assessed by operators with minimal 3DUS experience. MATERIAL AND METHODS: 260 stored volumes of fetal face were analyzed using a standardized protocol by operators with different levels of competence in 3DUS. The outcomes studied were: (1) the performance of post-processing 3D face volumes for the detection of facial clefts; (2) the ability of a resident with minimal 3DUS experience to reconstruct the acquired facial volumes, and (3) the time needed to reconstruct each plane to allow proper diagnosis of a cleft. RESULTS: The three orthogonal planes of the fetal face (axial, sagittal and coronal) were adequately reconstructed with similar performance when acquired by a maternal-fetal medicine specialist or by residents with minimal experience (72 vs. 76%, p = 0.629). The learning curve for manipulation of 3DUS volumes of the fetal face corresponds to 30 cases and is independent of the operator's level of experience. DISCUSSION: The learning curve for the standardized protocol we describe is short, even for inexperienced sonographers. This technique might decrease the length of anatomy ultrasounds and improve the ability to visualize fetal face anomalies.

[Influence of prenatal hospitalization on parental stressful experience in the case of a premature birth]. / Influence d'une hospitalisation prénatale sur les facteurs de stress parentaux lors d'une naissance prématurée.

OBJECTIVES: To investigate the influence of prenatal hospitalization before a premature birth, on the parental stressful experience, parental symptoms of post-traumatic stress and quality of parent-infant interaction during the hospitalization in neonatology. POPULATION: 51 preterm infants born and 25 full term infants control. Four groups: controls, premature without prenatal hospitalization, premature with a short (<8 days) prenatal hospitalization and premature with a long (≥ 8 days) prenatal hospitalization. INSTRUMENTS: the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU, Miles et al., 1993 [14]) and the Perinatal PTSD Questionnaire (PPQ, Quinnell and Hynan, 1999 [16]). RESULTS: When prenatal hospitalization of the mother occurred, parents acknowledged increased stress induced by the environmental factors during the infant's hospitalization. Furthermore, mothers from the group with a short prenatal hospitalization presented significantly more symptoms of post-traumatic stress. Parents presenting more symptoms of post-traumatic stress describe a significantly more difficult interaction with their infant in neonatology. CONCLUSION: This study highlights the necessity to deliver special care to women hospitalized shortly (<8 days) prior to the delivery of their premature baby. This group is at high risk of presenting post-traumatic stress symptoms, which could have a negative impact on the quality of parent-infant interactions.

Continuous recording intrarectal pressures during the second phase of labor.

UNLABELLED: Parameters of intrarectal pressure (surface area under pressure curve and peak pressure) recorded with a microsystem device during the second phase of labor showed no significant correlations with baby's weight or mode of delivery. AIM OF THE STUDY: Was to assess the biomechanical pressures delivered against pelvic floor structures during the second phase of labor in nulliparae women, and to correlate them with obstetrics parameters, i.e. baby's weight and mode of delivery. MATERIAL: Using a microsystem device placed into the rectum at the beginning of the second phase of labor, two parameters were assessed during the bearing efforts in 59 nulliparae women: the surface area under the pressure curve and the peak pressure. RESULTS: During 11.5±9 bearing efforts of 99.1±16 s duration, the mean value of surface area under the pressure curve was 32677±26058 cm/s and the mean value of the peak pressure was 60.7±24 cmH(2)O, exceeding 100 cmH(2)O in 10% of women. These two parameters were not correlated with baby's weight (R: 0.19, P: 0.15 and R: 0.05, P: 0.71). In the same way, these two parameters were not correlated with the mode of delivery (spontaneous or forceps/vacuum-assisted). Furthermore, the individual values of these two parameters showed great variation from one woman to another. CONCLUSION: This study has showed that parameters of biomechanical pressures recorded into the rectum during second phase of labor had no significant correlations with obstetricals parameters, explaining why these latter have poor predicitive value of further pelvic floor problems.

[Fast-track multimodal rehabilitation after cesarean, the sum of all tricks]. / Réhabilitation accélérée multimodate postcésarienne, la somme de toutes les astuces.

Fast-track multimodal rehabilitation after cesarean, the sum of all tricks Fast-track multimodal rehabilitation after caesarean is an interdisciplinary concept allowing an accelerated return to normal physiology. Fast-track rehabilitation combines minimising surgical trauma, regional anaesthesia and active management of pain control, minimally invasive postoperative care while promoting return to autonomy.

Anti-60-kDa heat shock protein antibodies in fetal serum: a biomarker for unexplained small for gestational age fetuses.

INTRODUCTION: Small for gestational age (SGA) is an important problem affecting 10% of pregnancies and is associated with significant perinatal morbidity. In about 80% of cases, a probable etiology or a major risk factor can be identified. But almost 20% of SGA cases are considered unexplained. The 60-kDa heat shock protein (HSP60) is a highly immunogenic protein whose synthesis is greatly upregulated under nonphysiological conditions. Bacterial and human HSP60 share a high degree of sequence homology, and immunity to conserved epitopes may result in development of autoimmunity following a bacterial infection. We hypothesized that unexplained SGA could be the consequence of immune sensitization to human HSP60. METHODS: Unexplained SGA fetuses were identified by ultrasound biometry with normal Doppler velocimetry and with no detectable maternal or fetal abnormalities. Fetal sera were obtained by cordocentesis performed for a karyotype analysis in cases of unexplained SGA (study group) or for screening of Rhesus incompatibility (control group). Fetal sera were tested for HSP60 antigen and for IgG and IgM anti-HSP60 by ELISA as well as for other immune and hematological parameters. RESULTS: Maternal parameters were similar between the 12 study cases and the 23 control cases. The mean gestational age at cordocentesis was 29 weeks. IgM anti-HSP60 was detected in 12 cases (100%) and in no controls (p < 0.00017), while IgG anti-HSP60 was detected in 7 cases (58%) and only 1 control (p < 0.001). Three of the 4 cases with the highest IgM antibody levels died. There were no differences in fetal serum levels of HSP60 antigen or other immune and hematological markers between the two groups. CONCLUSION: Fetuses with unexplained SGA are positive for IgM and IgG antibody to human HSP60 and the specific IgM antibody level is predictive of fetal mortality. Detection of these antibodies indicates that a placental perturbation and a fetal autoimmune reaction to HSP60 are associated with this developmental delay.

[Role of the PAP smear in adolescence]. / Place du frottis cytologique à l'adolescence.

The publication of the 2006 directives concerning the management of PAP smears has incited us to update our internal protocols at the CHUV, which are described in this article. A new addition to these directives is the specific management of adolescent PAP smears, who present both a high HPV carriage rate and increased incidence of cytological abnormalities with a favorable outcome in most cases. Our goal is to avoid over-treating dysplasias in this type of patient in order to avoid long-term complications. Emphasis is placed on the first gynecological consultation where a listening ear and clear and targeted information remain essential in the proper management of a young patient.

[In-vitro fertilization: advantage and disadvantage of covering the costs of IVF/ICSI by the health insurance in Switzerland]. / Fécondation in vitro: intérêt et désavantage du remboursement par l'assurance maladie en Suisse.

In-vitro fertilization: advantage and disadvantage of covering the costs of IVF/CSI by the health insurance in Switzerland The reimbursement of certain infertility treatments (stimulation with/without insemination) whereas IVF/ICSI is not leads patients with an indication of IVF to prefer treatments of low efficacy. The costs of multiple pregnancies issued by reimbursed or non-reimbursed fertility treatments are paid by the society. There should be measures to reduce these costs and to take the money used today to pay the complications of infertility treatments to reimburse IVF. The efficacy of such a system (single embryo transfer) has been proven in Belgium since several years. The dangers of complete reimbursement (IVF treatment in cases without any chances of success, only because it is for free) can be avoided by an Efficacy and Safety Board.

The contractile properties of vaginal myofibroblasts: is the myofibroblasts contraction force test a valuable indication of future prolapse development?

Using a specific myofibroblast contraction test, we try to predict future utero-vaginal prolapse development in young primiparae women. We compare myofibroblast cultures of the vaginal wall in primiparae women (group 1), young multiparae women (group 2) and older multiparae women (group 3) who were operated on for severe utero-vaginal prolapse. A myofibroblast-mediated collagen gel contraction assay determined a contraction factor that was compared in the three groups of women. The myofibroblasts contraction factor after 24 and 48 hours was significantly higher in group 1 women (2.4 +/- 0.6/4.4 +/- 1.9) compared to group 2 (1.6 +/- 0.3/ 1.8 +/- 0.1) andgroup 3 (1.6 +/- 0.3/1.8 +/- 0.3), but showed no differences in group 1 women without (2.1 +/- 0.5/3.5 +/- 1.9) and with (2.7 +/- 0.6/5.1 +/- 1.7) cystocoele. Vaginal myofibroblasts of young women show better contraction forces than young women with severe utero-vaginal prolapse. The latter have a myofibroblast contraction factor similar to those of older post-menopausal women operated for the same condition.

[Management of in utero foetal death: Which assessment to undertake?]. / Prise en charge de la mort in utero: quel bilan proposer?

OBJECTIVE: To assess the value of para-clinical exams prescribed in case of in utero foetal death, to result in the establishment of a new algorithm of diagnostic tests. MATERIALS AND METHODS: A retrospective analysis on a series of 106 stillbirths gathered between September 1989 and December 1998 in the obstetrical and gynaecological department of the Lausanne University Hospital which is a tertiary centre. Stillbirth was defined as foetal death occurring as from the date of foetal viability. Thus, only pregnancies from 24 weeks and onwards were included in this series. We excluded all stillbirths occurring during medical termination of pregnancy and cases with incomplete data files. The Fretts' classification was used. The different exams asked by the physician were screened and we analysed their pertinence to determine the aetiological diagnosis for each case. The search for significant risk factors was also taken into account. We compared our management of in utero foetal death with data from the literature to propose a new algorithm. RESULTS: The aetiology of in utero foetal death could be attributed in ninety percent of the cases. The principal causes were in utero growth retardation (19.8%), foetal congenital and chromosomal anomalies (18.9%), infections (15.1%), placental abruption (7.5%), preeclampsia (5.6%), maternal diabetes (3.8%). The remaining 18.9% are divided in to miscellaneous causes. In 10.4% of the cases we could not find any explanation to the death of the foetus. The exams that yielded the most information when done were: foetal autopsy which was abnormal in 92.7%, placental investigation which was abnormal in 93% and the babygramme (X-ray of the foetal skeleton) which was abnormal in 53%. Maternal serology for infections was informative in 6.6% of the cases. CONCLUSION: We present here a protocol for the diagnostic management of stillbirth which is differentiated according to the circumstances surrounding the event. This should prove useful to reduce superfluous tests.

[Management of postpartum haemorrhage]. / Prise en charge de l'hémorragie du post-partum.

Today, postpartum hemorrhage remains a leading cause of maternal morbidity and mortality. Medical treatment, various surgical procedures and/or uterine artery embolisation have considerably reduced the risk of hysterectomy. It is important to identify the different risk factors of hemorrhage after delivery and to take the precautions to avoid it. A clear strategy defined by the obstetrical team is essential to decrease the delay in the management of this complication in order to increase the chances of a successful treatment.

Association between fetal interleukin-1 receptor antagonist gene polymorphism and unexplained fetal death.

OBJECTIVE: In spite of extensive clinical examinations or autopsies, as many as 15% to 40% of stillbirths remain unexplained. A systemic fetal inflammatory response is an independent risk factor for severe neonatal morbidity, mediated by proinflammatory cytokines. As a major anti-inflammatory cytokine, interleukin-1 receptor antagonist (IL-1ra) plays a crucial role modulating the proinflammatory response. The gene coding for IL-1ra (IL1RN) is polymorphic. We hypothesized that fetal possession of a specific allele, IL-1RN*2, associated with increased proinflammatory responses, may increase susceptibility to intrauterine fetal death. STUDY DESIGN: Fetal kidney cells were obtained from paraffin blocks of 27 unexplained stillbirths. DNA was isolated and tested for IL-1RN genotypes by polymerase chain reaction. As a control group, DNA from 302 live births was also tested. RESULTS: There was an enhanced rate of IL-1RN*2 homozygocity, 41%, among unexplained stillbirths compared with the control group, 8.6% (P < .001). Histologic analysis of fetal tissues demonstrated a predominant proinflammatory response in IL-1RN*2 homozygote fetuses. Extensive screening (microbiology, maternal serology, placenta histology) did not identify any specific trigger agent. CONCLUSION: There is an association between unexplained stillbirth and fetal homozygous IL1RN*2 carriage.

Mycoplasma hominis in mid-trimester amniotic fluid: relation to pregnancy outcome.

OBJECTIVE: The relationship between detection of Mycoplasma hominis in mid-trimester amniotic fluid and subsequent pregnancy outcome was investigated. STUDY DESIGN: Amniotic fluids from 456 women of European background who underwent a transabdominal amniocentesis at weeks 15-17 of pregnancy were tested for M. hominis by polymerase chain reaction (PCR). The amplicons were hybridized to an internal probe and detected by ELISA. Pregnancy outcomes and clinical data were subsequently obtained. RESULTS: M. hominis were identified in 29 (6.4%) of the amniotic fluids. The rate of preterm labor in women positive for M. hominis (14.3%) was higher than in the negative women (3.3%) (p=0.01). Similarly, a spontaneous preterm birth with intact membranes occurred in 10.7% of the M. hominis-positive women as opposed to only 1.9% of the negative women (p = 0.02). The presence of this mycoplasma was not correlated with fetal chromosomal aberrations, intrauterine growth restriction or preeclampsia. CONCLUSIONS: Detection of M. hominis in second-trimester amniotic fluids can identify women at increased risk for subsequent preterm labor and delivery.

Effects of epidural analgesia on pelvic floor function after spontaneous delivery: a longitudinal retrospective study.

The aim of the study was to assess the effects of epidural analgesia on pelvic floor function. Eighty-two primiparous women (group 1, consisting of 41 given an epidural, and group 2 of 41 not given an epidural) were investigated during pregnancy and at 2 and 10 months after delivery by a questionnaire, clinical examination, and assessment of bladder neck behavior, urethral sphincter function and intravaginal/intra-anal pressures. The prevalence of stress urinary incontinence was similar in both groups at 2 months (24% vs. 17%, P = 0.6) and 10 months (22% vs. 7%, P = 0.1), as was the prevalence of decreased sexual vaginal response at 10 months (27% vs. 10%, P = 0.08). Bladder neck behavior, urethral sphincter function and intravaginal and intra-anal pressures showed no significant differences between the two groups. Ten months after spontaneous delivery, there were no significant differences in the prevalence of stress urinary incontinence and decreased sexual vaginal response, or in bladder neck behavior, urethral sphincter function and pelvic floor muscle strength between women who had or had not had epidural analgesia.

TAFI antigen and D-dimer levels during normal pregnancy and at delivery.

We have investigated whether the levels of thrombin-activatable fibrinolysis inhibitor (TAFI) were correlated with D-dimer levels during pregnancy and at delivery. From the 10th week of pregnancy to delivery, 519 samples from 144 women (mean age 29.3 +/- 5, range 19-43) were obtained. We confirm the gradual increase of D-dimer levels, and provide reference intervals for D-dimer measurements throughout normal pregnancy. TAFI levels increased moderately during pregnancy but no inverse correlation with D-dimer levels was observed.

Screening for foetal malformations: performance of routine ultrasonography in the population of the Swiss Canton of Vaud.

OBJECTIVE: To determine the sensitivity of ultrasonography in screening for foetal malformations in the pregnant women of the Swiss Canton of Vaud. STUDY DESIGN: Retrospective study over a period of five years. METHOD: We focused our study on 512 major or minor clinically relevant malformations detectable by ultrasonography. We analysed the global sensitivity of the screening and compared the performance of the tertiary centre with that of practitioners working in private practice or regional hospitals. RESULTS: Among the 512 malformations, 181 (35%) involved the renal and urinary tract system, 137 (27%) the heart, 71 (14%) the central nervous system, 50 (10%) the digestive system, 42 (8%) the face and 31 (6%) the limbs. Global sensitivity was 54.5%. The lowest detection rate was observed for cardiac anomalies, with only 23% correct diagnoses. The tertiary centre achieved a 75% detection rate in its outpatient clinic and 83% in referred patients. Outside the referral centre, the diagnostic rate attained 47%. CONCLUSIONS: Routine foetal examination by ultrasonography in a low-risk population can detect foetal structural abnormalities. Apart from the diagnosis of cardiac abnormalities, the results in the Canton of Vaud are satisfactory and justify routine screening for malformations in a low-risk population. A prerequisite is continuing improvement in the skills of ultrasonographers through medical education.

Prenatal diagnosis of urinary malformations: results in a series of 93 consecutive cases.

OBJECTIVE: To evaluate the pertinence of prenatal diagnosis in cases of congenital uropathy. STUDY DESIGN: Retrospective evaluation over a period of 6.5 years. METHOD: 93 cases were involved in the comparison of prenatal ultrasonographic diagnosis with neonatal findings, autopsy results, and follow-up data. RESULTS: 33 fetuses had renal parenchymal lesions, 44 had excretory system lesions, and 6 had bladder and/or urethral lesions. Seventy-three pregnancies lead to live births. Eighteen terminations of pregnancy were performed on the parents' request for extremely severe malformations. Two intrauterine deaths were observed, and two infants died in the postnatal period. Prenatal diagnosis was obtained at an average of 27 weeks gestation. Diagnostic concordance was excellent in 82% and partial in 12% of cases with renal parenchymal lesions; the false-positive rate was 6%. For excretory system lesions, concordance was excellent in 87% and partial in 7.4% of cases, with a false-positive rate of 5.6%. Finally, concordance was excellent in 100% of cases of bladder and/or urethral lesions. The overall rate of total concordance was 86%. Partial concordance cases consisted of malformations different from those previously diagnosed, but prenatal diagnosis nevertheless lead to further investigations in the neonatal period and to proper management. The false-positive diagnoses (5.4%) never lead to termination of pregnancy. CONCLUSION: Prenatal diagnosis of congenital uropathy is effective. A third-trimester ultrasonographic examination is necessary to ensure proper neonatal management, considering that the majority of cases are diagnosed at this gestational age.

Pelvic floor education after vaginal delivery.

OBJECTIVE: To assess the effect of pelvic floor education after vaginal delivery on pelvic floor characteristics in nulliparous women. METHODS: We examined 107 nulliparas during pregnancy and at 9 weeks and 10 months after vaginal delivery. Methods used included a questionnaire, clinical examination, perineosonography, urethral pressure profiles, and intravaginal and intra-anal pressure recordings during pelvic floor contraction. After the second examination, the women were assigned in alternating manner to either 12 sessions of pelvic floor exercises with biofeedback and electrostimulation (n = 51) or no training (n = 56). The two groups were compared at the third examination. RESULTS: Stress urinary incontinence incidence decreased in 2% of control subjects compared with 19% of women who underwent pelvic floor education (P =.002), whereas the incidence of fecal incontinence (5% versus 4%, P = 1) and the percentage of women who recovered predelivery pelvic floor contraction strength (33% versus 41%, P =.4) were no different. We observed no significant differences in bladder neck position and mobility, urethral functional length, maximal urethral closure pressure, pressure transmission ratio, residual area of continence at stress standing, or intravaginal or intra-anal pressures during pelvic floor contraction between groups at the third examination. CONCLUSION: Pelvic floor education, begun 2 months postpartum, significantly reduced the incidence of stress urinary incontinence, but not fecal incontinence or weak pelvic floor. Similarly, bladder neck behavior, urodynamic characteristics, intravaginal or intra-anal pressures during pelvic floor squeezing also were not modified.

Molar pregnancy with a coexistent fetus after intracytoplasmic sperm injection. A case report.

BACKGROUND: Normal fertilization is usually considered to have occurred when two pronculei (2PN) and two polar bodies are observed. Exceptions are the single pronucleated zygote resulting from asynchronous pronuclei. CASE: A 29-year-old woman entered a program of intracytoplasmic sperm injection and embryo transfer because of her husband's oligoasthenoteratozoospermia. Two cleavage-stage embryos (four blastomeres, grade 1 and 2) were obtained from one fertilized oocyte containing distinct 2PN and the other a single pronucleus (1PN). At 15 weeks' gestation the patient developed severe preeclampsia requiring termination of the pregnancy. Histopathologic examination and DNA ploidy by image analysis were consistent with a twin pregnancy combining a complete hydatidiform mole and normal pregnancy. CONCLUSION: We hypothesize that this 1PN was at the origin of the hydatidiform mole. This case highlights the danger of transferring an embryo having 1PN.